Healthcare Provider Details

I. General information

NPI: 1508225988
Provider Name (Legal Business Name): SHELL LAKE CLINIC, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 02/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 4TH AVE
SHELL LAKE WI
54871-4457
US

IV. Provider business mailing address

105 4TH AVE
SHELL LAKE WI
54871-4457
US

V. Phone/Fax

Practice location:
  • Phone: 715-468-2711
  • Fax: 715-468-2727
Mailing address:
  • Phone: 715-468-2711
  • Fax: 715-468-2727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number61281-20
License Number StateWI

VIII. Authorized Official

Name: DR. JEFFREY L. DUNHAM
Title or Position: PRESIDENT
Credential: M D
Phone: 715-468-2711