Healthcare Provider Details

I. General information

NPI: 1124328232
Provider Name (Legal Business Name): WEST BEND CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2010
Last Update Date: 10/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W227 N16857 TILLIE LAKE COURT
JACKSON WI
53037-9000
US

IV. Provider business mailing address

1700 W PARADISE DR
WEST BEND WI
53095
US

V. Phone/Fax

Practice location:
  • Phone: 262-365-6170
  • Fax:
Mailing address:
  • Phone: 262-334-3451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: JAMES BROWNE
Title or Position: ADMINISTRATOR
Credential:
Phone: 262-306-6536