Healthcare Provider Details

I. General information

NPI: 1962789362
Provider Name (Legal Business Name): EAU CLAIRE MEDICAL CLINIC, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2011
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 W HAMILTON AVE
EAU CLAIRE WI
54701-6938
US

IV. Provider business mailing address

703 W HAMILTON AVE
EAU CLAIRE WI
54701-6938
US

V. Phone/Fax

Practice location:
  • Phone: 715-839-9280
  • Fax: 715-839-9348
Mailing address:
  • Phone: 715-839-9280
  • Fax: 715-839-9348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateWI

VIII. Authorized Official

Name: DR. ANTON I KIDESS
Title or Position: DIRECTOR
Credential: MD
Phone: 715-839-9280