Basic Information
| Provider Information | |||||||||
| NPI: | 1780774760 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAY CARE COMPLEMENTARY HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2845 GREENBRIER RD | ||||||||
| Address2: | P O BOX 8900 SUITE 340 | ||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543116519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202888383 | ||||||||
| FaxNumber: | 9202888385 | ||||||||
| Practice Location | |||||||||
| Address1: | 2845 GREENBRIER RD | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543116519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202888383 | ||||||||
| FaxNumber: | 9202888385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SKOGMAN | ||||||||
| AuthorizedOfficialFirstName: | WADE | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 9202888383 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 2576 | WI | X | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 111N00000X | 2216 | WI | X | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 111N00000X | 3140 | WI | X | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 111N00000X | 2312 | WI | X | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 111NN0400X | 1783 | WI | X | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 38995400 | 05 | WI | MEDICAID |