Provider Demographics
NPI:1730628041
Name:CORNERSTONE CHIROPRACTIC OF HORTONVILLE LLC
Entity type:Organization
Organization Name:CORNERSTONE CHIROPRACTIC OF HORTONVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:BEDOR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-850-2507
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:HORTONVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54944-0187
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:223 N PINE ST
Practice Address - Street 2:
Practice Address - City:HORTONVILLE
Practice Address - State:WI
Practice Address - Zip Code:54944-9140
Practice Address - Country:US
Practice Address - Phone:920-850-2507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-20
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5233-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100064521Medicaid