Healthcare Provider Details

I. General information

NPI: 1649202128
Provider Name (Legal Business Name): ALLERGY & ASTHMA CLINIC OF KENOSHA SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 11/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4906 39TH AVE
KENOSHA WI
53144-2108
US

IV. Provider business mailing address

4906 39TH AVE
KENOSHA WI
53144-2108
US

V. Phone/Fax

Practice location:
  • Phone: 262-657-9390
  • Fax: 262-657-4666
Mailing address:
  • Phone: 262-657-9390
  • Fax: 262-657-4666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number StateWI

VIII. Authorized Official

Name: DR. KULWANT SINGH DHALIWAL
Title or Position: PRESIDENT
Credential: MD
Phone: 262-657-9390