MEDICARE: GUARDIAN PROPERTIES OF WISCONSIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BX2000X	Oxygen Equipment & Supplies (DME)

General Provider Information

NPI Number	:	1033354345
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GUARDIAN PROPERTIES OF WISCONSIN

Provider Business Mailing Address
First Line	:	10231 PENNY LAKE RD
Second Line	:
City	:	ROSHOLT
State	:	WI
Zip	:	54473-8862
Country	:	US
Telephone Number	:	715-677-4625
Fax Number	:

Provider Business Practice Location Address
First Line	:	10231 PENNY LAKE RD
Second Line	:
City	:	ROSHOLT
State	:	WI
Zip	:	54473-8862
Country	:	US
Telephone Number	:	715-677-4625
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. JAMES G WITUCKI
Credential	:
Telephone Number	:	715-677-4625

Provider Enumeration Date	:	12/16/2008
Last Update Date	:	12/16/2008

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