Provider Demographics
NPI:1902340375
Name:CHUDY CHIROPRACTIC CLINIC LLC
Entity Type:Organization
Organization Name:CHUDY CHIROPRACTIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:CHUDY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-501-2069
Mailing Address - Street 1:2304 N GRANDVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1602
Mailing Address - Country:US
Mailing Address - Phone:262-542-6900
Mailing Address - Fax:
Practice Address - Street 1:2304 N GRANDVIEW BLVD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1602
Practice Address - Country:US
Practice Address - Phone:262-542-6900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-05
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5223111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty