Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 2007 | WI |
NPI | 1003845587 |
---|---|
Provider Name | Dale R Alt |
First Address | Beaver Dam, WI 53916-2107 |
Second Address | Beaver Dam, WI 53916-2107 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
38833700 | (05) | WI |
T61355 | (02) | WI |