Provider Demographics
NPI:1528069317
Name:RETZLAFF, GERALD HARVEY (DC)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:HARVEY
Last Name:RETZLAFF
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2627 N CLAIREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-2405
Mailing Address - Country:US
Mailing Address - Phone:715-552-3232
Mailing Address - Fax:715-552-3233
Practice Address - Street 1:2627 N CLAIREMONT AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-2405
Practice Address - Country:US
Practice Address - Phone:715-552-3232
Practice Address - Fax:715-552-3233
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1370-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T63093Medicare UPIN
WI000020350Medicare PIN