Provider Demographics
NPI:1871935429
Name:VANDECASTLE FAMILY CHIROPRACTIC CLINIC
Entity type:Organization
Organization Name:VANDECASTLE FAMILY CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:VANDECASTLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-787-0122
Mailing Address - Street 1:PO BOX 512
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-0512
Mailing Address - Country:US
Mailing Address - Phone:920-787-0122
Mailing Address - Fax:920-787-0091
Practice Address - Street 1:140 N. TOWNLINE RD
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-0512
Practice Address - Country:US
Practice Address - Phone:920-787-0122
Practice Address - Fax:920-787-0091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-24
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3211-12261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38885200Medicaid
WIU53610Medicare UPIN