Healthcare Provider Details

I. General information

NPI: 1215493903
Provider Name (Legal Business Name): ELIZABETH BIANCHI KNOD CPO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2019
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5027 GREEN BAY RD STE 124
KENOSHA WI
53144-1771
US

IV. Provider business mailing address

5027 GREEN BAY RD STE 124
KENOSHA WI
53144-1771
US

V. Phone/Fax

Practice location:
  • Phone: 262-654-4300
  • Fax: 262-654-4305
Mailing address:
  • Phone: 262-654-4300
  • Fax: 262-654-4305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberCPO04219
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCPO04219
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: