Healthcare Provider Details

I. General information

NPI: 1417919275
Provider Name (Legal Business Name): PADDOCK LAKE FAMILY PRACTICE, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7137 236TH AVE SUITE 103
SALEM WI
53168-9664
US

IV. Provider business mailing address

7137 236TH AVE SUITE 103
SALEM WI
53168-9664
US

V. Phone/Fax

Practice location:
  • Phone: 262-843-4422
  • Fax: 262-843-1166
Mailing address:
  • Phone: 262-843-4422
  • Fax: 262-843-1166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. LISA M THOMAS
Title or Position: BILLING MANAGER
Credential:
Phone: 262-843-2394