MEDICARE: WELLNESS CHIROPRACTIC CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	3149	WI
2	111N00000X	Chiropractor	3025	WI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000235820	OTHER	WI	MEDICARE
2	000135820	OTHER	WI	MEDICARE

General Provider Information

NPI Number	:	1952467995
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLNESS CHIROPRACTIC CENTER LLC

Provider Business Mailing Address
First Line	:	816 WEST ST
Second Line	:
City	:	WATERTOWN
State	:	WI
Zip	:	53094-3601
Country	:	US
Telephone Number	:	920-262-0200
Fax Number	:	920-262-0210

Provider Business Practice Location Address
First Line	:	816 WEST ST
Second Line	:
City	:	WATERTOWN
State	:	WI
Zip	:	53094-3608
Country	:	US
Telephone Number	:	920-262-0200
Fax Number	:	920-262-0210

Authorized Official
Title or Position	:	CO OWNER
Name	:	DR. JANE E BROTSKI
Credential	:	DC DICCP
Telephone Number	:	920-262-0200

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	09/24/2010

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