Healthcare Provider Details

I. General information

NPI: 1780514695
Provider Name (Legal Business Name): SUSAN J BACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 RAIDER DR
ARCADIA WI
54612-9000
US

IV. Provider business mailing address

730 RAIDER DR
ARCADIA WI
54612-9000
US

V. Phone/Fax

Practice location:
  • Phone: 608-323-3315
  • Fax: 608-323-2256
Mailing address:
  • Phone: 608-323-3315
  • Fax: 608-323-2256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number32961-31
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: