Provider Demographics
NPI:1174723084
Name:BRUNS CHIROPRACTIC OFFICE SC
Entity type:Organization
Organization Name:BRUNS CHIROPRACTIC OFFICE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CLARENCE
Authorized Official - Last Name:BRUNS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-458-8252
Mailing Address - Street 1:1429 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53083-4760
Mailing Address - Country:US
Mailing Address - Phone:920-458-8252
Mailing Address - Fax:920-458-3942
Practice Address - Street 1:1429 NORTH AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53083-4760
Practice Address - Country:US
Practice Address - Phone:920-458-8252
Practice Address - Fax:920-458-3942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1362-012261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38982300Medicaid
75489Medicare PIN