Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | 1512 | WI |
Y | 111NX0800X | Chiropractor Orthopedic Specialist | 1512 | WI |
NPI | 1215064597 |
---|---|
Provider Name | Glenn R Wysocki |
First Address | Kenosha, WI 53143-5701 |
Second Address | Kenosha, WI 53143-5701 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/02/2007 |
Last Update Date | 09/12/2011 |