Provider Demographics
NPI:1679674873
Name:BREITBACH, JOHN EDWARD (DC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:EDWARD
Last Name:BREITBACH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:WI
Mailing Address - Zip Code:53575
Mailing Address - Country:US
Mailing Address - Phone:608-835-5353
Mailing Address - Fax:608-835-8990
Practice Address - Street 1:167 N MAIN ST
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:WI
Practice Address - Zip Code:53575
Practice Address - Country:US
Practice Address - Phone:608-835-5353
Practice Address - Fax:608-835-8990
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3295111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor