Provider Demographics
NPI:1871620310
Name:STAFFORD CHIROPRACTIC
Entity type:Organization
Organization Name:STAFFORD CHIROPRACTIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:STAFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-785-1811
Mailing Address - Street 1:PO BOX 510444
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-0444
Mailing Address - Country:US
Mailing Address - Phone:262-785-1811
Mailing Address - Fax:262-785-9887
Practice Address - Street 1:3333 S SUNNYSLOPE RD
Practice Address - Street 2:108
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-4502
Practice Address - Country:US
Practice Address - Phone:262-785-1811
Practice Address - Fax:262-785-9887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3258111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38921800Medicaid
WI000035803Medicare PIN