Healthcare Provider Details

I. General information

NPI: 1124708045
Provider Name (Legal Business Name): MACKENZIE SUE MEWS HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2023
Last Update Date: 07/25/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 E GENEVA SQ
LAKE GENEVA WI
53147-9694
US

IV. Provider business mailing address

166 E GENEVA SQ
LAKE GENEVA WI
53147-9694
US

V. Phone/Fax

Practice location:
  • Phone: 262-475-0880
  • Fax:
Mailing address:
  • Phone: 262-475-0880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2018-60
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: