MEDICARE: PAIN CENTERS OF WISCONSIN - SAUK PRAIRIE, 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	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1922415728
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAIN CENTERS OF WISCONSIN - SAUK PRAIRIE, LLC

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

Provider Business Practice Location Address
First Line	:	250 26TH ST
Second Line	:	SUITE 140
City	:	PRAIRIE DU SAC
State	:	WI
Zip	:	53578-2204
Country	:	US
Telephone Number	:	414-325-7246
Fax Number	:	414-325-3770

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

Provider Enumeration Date	:	07/14/2014
Last Update Date	:	10/24/2016

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