Healthcare Provider Details

I. General information

NPI: 1962974485
Provider Name (Legal Business Name): SOUTHWEST HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2018
Last Update Date: 05/27/2020
Certification Date: 05/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 IHM ST
LANCASTER WI
53813-9458
US

IV. Provider business mailing address

1400 EASTSIDE RD
PLATTEVILLE WI
53818-9800
US

V. Phone/Fax

Practice location:
  • Phone: 608-723-2020
  • Fax:
Mailing address:
  • Phone: 608-348-2331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: JESSE SOOKOCHOFF
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 608-342-4705