Healthcare Provider Details

I. General information

NPI: 1518167477
Provider Name (Legal Business Name): WEST GROVE CLINIC, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 11/12/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10012 W. CAPITOL DR. #101
WAUWATOSA WI
53222-1300
US

IV. Provider business mailing address

10012 W. CAPITOL DR #101
WAUWATOSA WI
53222-1300
US

V. Phone/Fax

Practice location:
  • Phone: 414-810-4844
  • Fax: 414-810-4845
Mailing address:
  • Phone: 414-810-4844
  • Fax: 414-810-4845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number2318
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: SELAHATTIN S. KURTER
Title or Position: EXECUTIVE DIRECTOR
Credential: MD
Phone: 414-810-4844