1922415728 NPI number — PAIN CENTERS OF WISCONSIN - SAUK PRAIRIE, 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 1922415728 NPI number — PAIN CENTERS OF WISCONSIN - SAUK PRAIRIE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN CENTERS OF WISCONSIN - SAUK PRAIRIE, 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:
1922415728
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4131 W LOOMIS RD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
GREENFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53221-2057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-325-7246
Provider Business Mailing Address Fax Number:
414-325-3770

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 26TH ST
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
PRAIRIE DU SAC
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53578-2204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-325-7246
Provider Business Practice Location Address Fax Number:
414-325-3770
Provider Enumeration Date:
07/14/2014

Additional Information

Authorized Official

Authorized Official Last Name:
LAL
Authorized Official First Name:
VISHAL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
414-325-7246

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)





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