1841281367 NPI number — HEALTH AND WELLNESS CLINIC OF SHOREWOOD, S.C.

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 1841281367 NPI number — HEALTH AND WELLNESS CLINIC OF SHOREWOOD, S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTH AND WELLNESS CLINIC OF SHOREWOOD, S.C.
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:
1841281367
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6400 INDUSTRIAL LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENDALE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53129-2452
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-423-4100
Provider Business Mailing Address Fax Number:
414-423-4134

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3510 N OAKLAND AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
SHOREWOOD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53211-2746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-967-9440
Provider Business Practice Location Address Fax Number:
414-967-9450
Provider Enumeration Date:
11/03/2005

Additional Information

Authorized Official

Authorized Official Last Name:
TOTODOVA
Authorized Official First Name:
ZINOVIYA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
414-967-9440

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 21280400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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