Provider Demographics
NPI:1235139353
Name:DETERT CHIROPRACTIC OFFICE SC
Entity type:Organization
Organization Name:DETERT CHIROPRACTIC OFFICE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:LEANNE
Authorized Official - Last Name:DETERT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-754-2555
Mailing Address - Street 1:PO BOX 485
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:WI
Mailing Address - Zip Code:54950-0485
Mailing Address - Country:US
Mailing Address - Phone:715-754-2555
Mailing Address - Fax:715-754-2559
Practice Address - Street 1:1101 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:WI
Practice Address - Zip Code:54950-9182
Practice Address - Country:US
Practice Address - Phone:715-754-2555
Practice Address - Fax:715-754-2559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-29
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2895-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIOFF38984900Medicaid
WILAURA38866500Medicaid
U32608Medicare UPIN
WILAURA38866500Medicaid