Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | 1651 | WI |
NPI | 1528118635 |
---|---|
Provider Name | Dr. Roy W Mutsch |
First Address | Cedarburg, WI 53012-3234 |
Second Address | Brown Deer, WI 53223-3764 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/01/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
38908100 | (05) | WI |
T62837 | (02) | WI |