Provider Demographics
NPI:1487000337
Name:CHIROPRACTIC SPINE & REHAB CENTER, S.C.
Entity type:Organization
Organization Name:CHIROPRACTIC SPINE & REHAB CENTER, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:OTTO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:414-321-1500
Mailing Address - Street 1:2349 S 108TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-1927
Mailing Address - Country:US
Mailing Address - Phone:414-321-1500
Mailing Address - Fax:414-321-1506
Practice Address - Street 1:2349 S 108TH ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-1927
Practice Address - Country:US
Practice Address - Phone:414-321-1500
Practice Address - Fax:414-321-1506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4315-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty