Healthcare Provider Details

I. General information

NPI: 1689220527
Provider Name (Legal Business Name): DELO SPORT AND STEM SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2595 DEVELOPMENT DR STE 140
GREEN BAY WI
54311-4267
US

IV. Provider business mailing address

2595 DEVELOPMENT DR STE 140
GREEN BAY WI
54311-4267
US

V. Phone/Fax

Practice location:
  • Phone: 920-632-7248
  • Fax: 920-632-4249
Mailing address:
  • Phone: 920-632-7248
  • Fax: 920-632-4249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARJORIE JEAN DELO
Title or Position: PRESIDENT
Credential: MD
Phone: 920-632-7248