Healthcare Provider Details

I. General information

NPI: 1649511304
Provider Name (Legal Business Name): WAUWATOSA PAIN MANAGEMENT , LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2013
Last Update Date: 07/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6005 W NORTH AVE
WAUWATOSA WI
53213-1527
US

IV. Provider business mailing address

6005 W NORTH AVE
WAUWATOSA WI
53213-1527
US

V. Phone/Fax

Practice location:
  • Phone: 414-530-2477
  • Fax: 414-771-6311
Mailing address:
  • Phone: 414-530-2477
  • Fax: 414-771-6311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JUSTIN HANSON
Title or Position: OWNER
Credential:
Phone: 414-530-2477