Healthcare Provider Details

I. General information

NPI: 1619069630
Provider Name (Legal Business Name): ST. CROIX VALLEY SURGICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 3RD AVENUE
OSCEOLA WI
54020-0597
US

IV. Provider business mailing address

204 3RD AVENUE PO BOX 597
OSCEOLA WI
54020-0597
US

V. Phone/Fax

Practice location:
  • Phone: 715-294-4898
  • Fax:
Mailing address:
  • Phone: 715-294-4898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number38459
License Number StateWI

VIII. Authorized Official

Name: JESSICA LARSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 715-294-4898