Provider Demographics
NPI:1174092779
Name:CHIROPRACTIC AND REHAB CENTER LLC
Entity type:Organization
Organization Name:CHIROPRACTIC AND REHAB CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-479-1514
Mailing Address - Street 1:W10436 KRATCHE RD
Mailing Address - Street 2:
Mailing Address - City:ELROY
Mailing Address - State:WI
Mailing Address - Zip Code:53929-9701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:840 WATER AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:WI
Practice Address - Zip Code:54634-6213
Practice Address - Country:US
Practice Address - Phone:608-489-4263
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-13
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1568938371Medicaid