Provider Demographics
NPI:1730578915
Name:BLACK CREEK CHIROPRACTIC OFFICE LLC
Entity type:Organization
Organization Name:BLACK CREEK CHIROPRACTIC OFFICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARREL
Authorized Official - Middle Name:D
Authorized Official - Last Name:KLEMP
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-984-3353
Mailing Address - Street 1:PO BOX 261
Mailing Address - Street 2:
Mailing Address - City:BLACK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:54106-0261
Mailing Address - Country:US
Mailing Address - Phone:920-984-3353
Mailing Address - Fax:920-984-3354
Practice Address - Street 1:411 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACK CREEK
Practice Address - State:WI
Practice Address - Zip Code:54106-9501
Practice Address - Country:US
Practice Address - Phone:920-984-3353
Practice Address - Fax:920-984-3354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty