Provider Demographics
NPI:1902146160
Name:BLACK EARTH CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:BLACK EARTH CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:REESON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-798-3437
Mailing Address - Street 1:9749 KAHL RD
Mailing Address - Street 2:
Mailing Address - City:BLACK EARTH
Mailing Address - State:WI
Mailing Address - Zip Code:53515-9516
Mailing Address - Country:US
Mailing Address - Phone:608-767-2226
Mailing Address - Fax:
Practice Address - Street 1:9749 KAHL RD
Practice Address - Street 2:
Practice Address - City:BLACK EARTH
Practice Address - State:WI
Practice Address - Zip Code:53515-9516
Practice Address - Country:US
Practice Address - Phone:608-767-2226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-26
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4130-012261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service