Healthcare Provider Details

I. General information

NPI: 1881789907
Provider Name (Legal Business Name): MED ALLIANCE S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 06/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 W. SILVER SPRING DR.
GLENDALE WI
53217
US

IV. Provider business mailing address

309 W. SILVER SPRING DR.
GLENDALE WI
53217
US

V. Phone/Fax

Practice location:
  • Phone: 414-961-7100
  • Fax: 414-961-7772
Mailing address:
  • Phone: 414-961-7100
  • Fax: 414-961-7772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. KENNETH A HOWARD
Title or Position: EXECUTIVE DIRECTOR
Credential: D.C.
Phone: 414-961-7100