Healthcare Provider Details

I. General information

NPI: 1922164656
Provider Name (Legal Business Name): PROCARE MEDICAL GROUP SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3727 W WISCONSIN AVE
MILWAUKEE WI
53208-3182
US

IV. Provider business mailing address

3727 W WISCONSIN AVE
MILWAUKEE WI
53208-3182
US

V. Phone/Fax

Practice location:
  • Phone: 414-291-2626
  • Fax: 414-291-2630
Mailing address:
  • Phone: 414-291-2626
  • Fax: 414-291-2630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateWI

VIII. Authorized Official

Name: ROSALINA VALLE
Title or Position: OFFICE MANAGER
Credential:
Phone: 414-291-2624