Lake Delton Chiropractic Clinic LLC
Organization Active NPI Chiropractor · Wisconsin Dells, WI
NPI 1619087871 · NPPES record last updated May 17, 2019
Key facts
- NPI
- 1619087871
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Chiropractor 111N00000X
- License
- 4029-012 (WI)
- Legal business name
- LAKE DELTON CHIROPRACTIC CLINIC LLC
- Practice address
- 151 Wisconsin Dells Pkwy S
Wisconsin Dells, WI 53965 - Phone
- (608) 253-0102
- Fax
- (608) 253-0188
- NPI assigned
- Aug 30, 2006
- Organization subpart
- No
Authorized official
- Name
- Dr. Todd Joseph Bauer, D.C.
- Title
- Owner
- Phone
- (608) 697-9994
Practitioners 1
-
Todd Joseph Bauer, D.C.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in WI
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20190607000659 | WI | Part B Supplier - Clinic/Group Practice | 9739412693 |
Receives reassigned benefits from 1 practitioner Practice locations: Wisconsin Dells, WI |
National Provider Directory
Locations
306 W Cook St
Portage, WI 53901
Phone (608) 742-2225
151 Wisconsin Dells Pkwy S
Wisconsin Dells, WI 53965
Phone (608) 253-0102
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Chiropractor |
111N00000X | 4029-012 | WI | Yes |
Addresses
Primary practice location
151 Wisconsin Dells Pkwy S
Wisconsin Dells, WI 53965
Mailing address
151 Wisconsin Dells Pkwy S
Wisconsin Dells, WI 53965
Phone (608) 253-0102
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 39000300 | Medicaid | WI |
Other names
- HealthSource Chiropractic & Progressive Wellness
Other providers in Wisconsin Dells, WI
- Daniel Edward Joseph
- Robert Ryan Kaas
- Kimberly A Kelly
- Daryl Francis Kemna
- Cheryl Lynn Kolf
- Tamara Marie Laskowski
- Britney Ann Leege
- Betsy Ann Long
- Megan Long
- Karin Lyn Luther
All providers in Wisconsin Dells, WI · Chiropractor in Wisconsin
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 17, 2019. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.