1053562959 NPI number — PROHEALTH ALIGNED LLC

Table of content: (NPI 1053562959)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053562959 NPI number — PROHEALTH ALIGNED LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROHEALTH ALIGNED LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PROHEALTH CARE MORELAND SURGERY CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053562959
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 DELAFIELD ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
WAUKESHA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53188-3417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-928-4300
Provider Business Mailing Address Fax Number:
262-928-4333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 DELAFIELD ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
WAUKESHA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53188-3417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-928-4300
Provider Business Practice Location Address Fax Number:
262-928-4333
Provider Enumeration Date:
10/09/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BULLEN
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
G
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
262-928-6080

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)