Healthcare Provider Details

I. General information

NPI: 1043220692
Provider Name (Legal Business Name): WEST BEND CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 05/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 E PARADISE DR
WEST BEND WI
53095-5444
US

IV. Provider business mailing address

1700 W PARADISE DR
WEST BEND WI
53095-9795
US

V. Phone/Fax

Practice location:
  • Phone: 262-306-6319
  • Fax:
Mailing address:
  • Phone: 262-334-3451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: GREGORY G BLOMMEL
Title or Position: ADMINISTRATOR
Credential:
Phone: 262-334-3451