=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063188373
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MACKENZIE KREMER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2021
-----------------------------------------------------
Last Update Date | 08/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1829 N MAIN ST
-----------------------------------------------------
City | WEST BEND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53090-1547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-483-5750
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1335 DAISY DR
-----------------------------------------------------
City | WEST BEND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53090-2700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-483-5750
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 960-55
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------