Provider Demographics
NPI:1861518623
Name:BLANCHARDVILLE CHIROPRACTIC CLINIC, SC
Entity type:Organization
Organization Name:BLANCHARDVILLE CHIROPRACTIC CLINIC, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:R
Authorized Official - Last Name:SCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC, DABCI
Authorized Official - Phone:608-523-4612
Mailing Address - Street 1:P.O. BOX 56
Mailing Address - Street 2:320 S. MAIN ST.
Mailing Address - City:BLANCHARDVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53516-0056
Mailing Address - Country:US
Mailing Address - Phone:608-523-4612
Mailing Address - Fax:608-523-4614
Practice Address - Street 1:320 S. MAIN ST.
Practice Address - Street 2:
Practice Address - City:BLANCHARDVILLE
Practice Address - State:WI
Practice Address - Zip Code:53516-0056
Practice Address - Country:US
Practice Address - Phone:608-523-4612
Practice Address - Fax:608-523-4614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3562-012111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NI0900XChiropractic ProvidersChiropractorInternistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U76053Medicare UPIN
WI35537Medicare PIN