Healthcare Provider Details

I. General information

NPI: 1104042902
Provider Name (Legal Business Name): WISCONSIN CENTER FOR MYOFASCIAL RELEASE, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 08/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4103 60TH ST
KENOSHA WI
53144-2509
US

IV. Provider business mailing address

4103 60TH ST
KENOSHA WI
53144-2509
US

V. Phone/Fax

Practice location:
  • Phone: 262-652-1111
  • Fax: 262-652-1124
Mailing address:
  • Phone: 262-652-1111
  • Fax: 262-652-1124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number3534-026
License Number StateWI

VIII. Authorized Official

Name: MRS. PRISCILLA LINDA HORSWELL
Title or Position: OFFICE MANAGER
Credential:
Phone: 262-652-1111