Healthcare Provider Details

I. General information

NPI: 1497897565
Provider Name (Legal Business Name): CONSULTANTS LABORATORY OF WISCONSIN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 12/16/2022
Certification Date: 12/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 W STATE ST
FOX LAKE WI
53933-9550
US

IV. Provider business mailing address

430 E DIVISION ST
FOND DU LAC WI
54935-4560
US

V. Phone/Fax

Practice location:
  • Phone: 920-926-5840
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. DEBORAH CHRISTIAN
Title or Position: PATIENT ACCOUNTS SUPERVISOR
Credential:
Phone: 920-926-5840