Provider Demographics
NPI:1780791624
Name:STEVENS CHIROPRACTIC SC
Entity type:Organization
Organization Name:STEVENS CHIROPRACTIC SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER CHIROPRACTIC
Authorized Official - Prefix:MR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-459-9500
Mailing Address - Street 1:PO BOX 610
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-0610
Mailing Address - Country:US
Mailing Address - Phone:920-459-9500
Mailing Address - Fax:920-459-9506
Practice Address - Street 1:1031 N 8TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081
Practice Address - Country:US
Practice Address - Phone:920-459-9500
Practice Address - Fax:920-459-9506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2740111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38864800Medicaid
WI38864800Medicaid
WI=========012OtherBCBS
WIWI1688Medicare PIN
WI000070382Medicare ID - Type Unspecified