MEDICARE: SHIVAM 2 HOLDINGS LLC

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	208100000X	Physical Medicine & Rehabilitation Physician
2	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1669047874
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHIVAM 2 HOLDINGS LLC

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

Provider Business Practice Location Address
First Line	:	3221 VOYAGER DR
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54311-8349
Country	:	US
Telephone Number	:	920-256-0392
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RAVI PATEL
Credential	:	DC
Telephone Number	:	920-256-0392

Provider Enumeration Date	:	05/21/2021
Last Update Date	:	05/06/2022

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