Healthcare Provider Details

I. General information

NPI: 1548606767
Provider Name (Legal Business Name): BYRON HEALTH AND HEALING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2013
Last Update Date: 05/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 NORTHWESTERN AVE LOWER LEVEL, STE 15
RACINE WI
53404-2534
US

IV. Provider business mailing address

2405 NORTHWESTERN AVE LOWER LEVEL, STE 15
RACINE WI
53404-2534
US

V. Phone/Fax

Practice location:
  • Phone: 262-498-3718
  • Fax:
Mailing address:
  • Phone: 262-498-3718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number42218-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number42218-20
License Number StateWI

VIII. Authorized Official

Name: JAMES K IRUNGU
Title or Position: BILLING MANAGER
Credential:
Phone: 678-353-7073