Healthcare Provider Details

I. General information

NPI: 1003108515
Provider Name (Legal Business Name): CLINICA PANAMERICANA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2011
Last Update Date: 05/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 W HISTORIC MITCHELL ST 211
MILWAUKEE WI
53204-3383
US

IV. Provider business mailing address

1225 W HISTORIC MITCHELL ST 211
MILWAUKEE WI
53204-3383
US

V. Phone/Fax

Practice location:
  • Phone: 414-389-0166
  • Fax: 414-643-1003
Mailing address:
  • Phone: 414-389-0166
  • Fax: 414-643-1003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number26560-20
License Number StateWI

VIII. Authorized Official

Name: HUGO F GOITIA
Title or Position: PRESIDENT
Credential: MD
Phone: 414-389-0166