Healthcare Provider Details

I. General information

NPI: 1902133994
Provider Name (Legal Business Name): WISCONSIN SPINAL REHABILITATION CENTER, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2009
Last Update Date: 01/13/2020
Certification Date: 01/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21180 W CAPITOL DR
BROOKFIELD WI
53072-2915
US

IV. Provider business mailing address

21180 W CAPITOL DR
BROOKFIELD WI
53072-2915
US

V. Phone/Fax

Practice location:
  • Phone: 262-695-1870
  • Fax: 262-695-1872
Mailing address:
  • Phone: 262-695-1870
  • Fax: 262-695-1872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number3022
License Number StateWI

VIII. Authorized Official

Name: MRS. ELIZABETH VASQUEZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 262-695-1870