Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | 2193 | WI |
NPI | 1023000791 |
---|---|
Provider Name | Jeffrey R Lyne |
First Address | Sun Prairie, WI 53590-1839 |
Second Address | Sun Prairie, WI 53590-1839 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/08/2005 |
Last Update Date | 08/11/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
38797600 | (05) | WI |
T62653 | (02) | WI |