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General NPI Number Information
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NPI Number | 1104913623
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Entity Type | Organization
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Legal Business Name | PREMIER PHYSICAL MEDICINE AND WELLNESS CLINIC
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Dates
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Enumeration Date | 10/06/2006
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Last Update Date | 01/08/2009
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Provider Practice Location Address
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Address Line | 1446 1ST AVE
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City | WOODRUFF
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State | WI
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Zip | 54568-9149
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Country | US
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Telephone | 715-356-9999
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Fax | 715-356-9894
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Provider Business Mailing Address
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Address Line | PO BOX 1550
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City | WOODRUFF
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State | WI
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Zip | 54568-1550
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Country | US
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Telephone | 715-356-9999
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Fax | 715-356-9894
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Authorized Official
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Title or Position | OWNER
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Name | JAMES E MULLEN
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Credential | M.D.
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Telephone | 715-356-9999
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 33657
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License Number State | WI
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