Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 4936-12 | WI |
NPI | 1003257254 |
---|---|
Provider Name | Dr. Jordan Mark Kluewer |
First Address | Hustisford, WI 53034 |
Second Address | Hustisford, WI 53034 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/07/2013 |
Last Update Date | 16/07/2013 |