Healthcare Provider Details

I. General information

NPI: 1407978521
Provider Name (Legal Business Name): WESTSIDE HEALTHCARE ASSOCIATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1452 N. 7TH STREET
MILWAUKEE WI
53205
US

IV. Provider business mailing address

3522 W. LISBON AVENUE
MILWAUKEE WI
53208
US

V. Phone/Fax

Practice location:
  • Phone: 414-287-0919
  • Fax: 414-287-0907
Mailing address:
  • Phone: 414-935-8000
  • Fax: 414-934-6081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number38021
License Number StateWI

VIII. Authorized Official

Name: MS. JENNI SEVENICH
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 414-935-8000