Healthcare Provider Details

I. General information

NPI: 1609289214
Provider Name (Legal Business Name): ELLEN IGL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 06/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N8053 HWY 33
BEAVER DAM WI
53916-9762
US

IV. Provider business mailing address

N8053 HWY 33
BEAVER DAM WI
53916-9762
US

V. Phone/Fax

Practice location:
  • Phone: 920-885-4144
  • Fax:
Mailing address:
  • Phone: 920-885-4144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: