1669257390 NPI number — OSL 10507 OAK CREEK OPERATING LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669257390 NPI number — OSL 10507 OAK CREEK OPERATING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OSL 10507 OAK CREEK OPERATING 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:
Provider Other Organization Name Type Code:
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:
1669257390
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2448 S 102ND ST STE 305
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST ALLIS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53227-2141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-214-8950
Provider Business Mailing Address Fax Number:
414-755-1315

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10507 S CHICAGO RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK CREEK
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53154-6605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-764-3303
Provider Business Practice Location Address Fax Number:
414-764-8156
Provider Enumeration Date:
08/30/2023

Additional Information

Authorized Official

Authorized Official Last Name:
TERESINSKI
Authorized Official First Name:
MATT
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
414-324-5172

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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