Healthcare Provider Details

I. General information

NPI: 1124469978
Provider Name (Legal Business Name): PAIN CENTERS OF WISCONSIN - STEVENS POINT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2013
Last Update Date: 10/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 DIVISION ST STE H
STEVENS POINT WI
54481-1843
US

IV. Provider business mailing address

4131 W LOOMIS RD STE 300
GREENFIELD WI
53221-2057
US

V. Phone/Fax

Practice location:
  • Phone: 414-325-7246
  • Fax: 414-325-3770
Mailing address:
  • Phone: 414-325-7246
  • Fax: 414-325-3770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VISHAL LAL
Title or Position: CEO
Credential:
Phone: 414-325-3737