Healthcare Provider Details

I. General information

NPI: 1275542607
Provider Name (Legal Business Name): WEST BEND CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 05/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W225N16711 CEDAR PARK CT
JACKSON WI
53037-9222
US

IV. Provider business mailing address

1700 W PARADISE DR
WEST BEND WI
53095-9795
US

V. Phone/Fax

Practice location:
  • Phone: 262-677-1101
  • Fax:
Mailing address:
  • Phone: 262-334-3451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GREGORY G BLOMMEL
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 262-334-3451