Healthcare Provider Details

I. General information

NPI: 1164130266
Provider Name (Legal Business Name): SOUTHWEST HEALTH CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2022
Last Update Date: 11/08/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3695 PRISM LANE
KIELER WI
53812-0263
US

IV. Provider business mailing address

1400 EASTSIDE RD
PLATTEVILLE WI
53818-9800
US

V. Phone/Fax

Practice location:
  • Phone: 608-348-2331
  • Fax:
Mailing address:
  • Phone: 608-348-2331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESSE SOOKOCHOFF
Title or Position: CFO
Credential:
Phone: 608-342-4705