Healthcare Provider Details

I. General information

NPI: 1730909664
Provider Name (Legal Business Name): EC LASER AND SURGERY INSTITUTE OF WI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2024
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 STANLEY ST
STEVENS POINT WI
54481-1323
US

IV. Provider business mailing address

800 N 1ST ST
WAUSAU WI
54403-4754
US

V. Phone/Fax

Practice location:
  • Phone: 715-298-5500
  • Fax:
Mailing address:
  • Phone: 715-261-8500
  • Fax:

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: KIMBERLY GODDARD
Title or Position: CHIEF OPERATING OFFICER
Credential: COO
Phone: 715-261-8557