Healthcare Provider Details

I. General information

NPI: 1447799580
Provider Name (Legal Business Name): GENEVA SURGICAL SUITES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2017
Last Update Date: 05/12/2020
Certification Date: 05/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 ELIZABETH LANE
GENOA CITY WI
53128-2124
US

IV. Provider business mailing address

119 ELIZABETH LN
GENOA CITY WI
53128-2124
US

V. Phone/Fax

Practice location:
  • Phone: 262-295-1213
  • Fax: 262-295-1221
Mailing address:
  • Phone: 262-295-1213
  • Fax: 262-295-1221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KRISTEN ROEKER
Title or Position: BUSINESS ADMINISTRATOR
Credential:
Phone: 262-295-1216