Basic Information
| Provider Information | |||||||||
| NPI: | 1649679721 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAPITOL CHIROPRACTIC, SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6400 INDUSTRIAL LOOP | ||||||||
| Address2: | |||||||||
| City: | GREENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531292452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144234100 | ||||||||
| FaxNumber: | 4144234134 | ||||||||
| Practice Location | |||||||||
| Address1: | 6125 W CAPITOL DR | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532162119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4145369022 | ||||||||
| FaxNumber: | 4145366688 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2014 | ||||||||
| LastUpdateDate: | 08/14/2014 | ||||||||
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| AuthorizedOfficialLastName: | RAY | ||||||||
| AuthorizedOfficialFirstName: | JODI | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4145369022 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
No ID Information.