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General NPI Number Information
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NPI Number | 1194216416
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Entity Type | Organization
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Legal Business Name | ST GEORGE CLINICS, LLC
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Dates
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Enumeration Date | 05/22/2018
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Last Update Date | 11/20/2023
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Provider Practice Location Address
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Address Line | 308 E MAIN ST
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City | WATERFORD
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State | WI
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Zip | 53185-4306
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Country | US
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Telephone | 262-923-3777
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Fax |
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Provider Business Mailing Address
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Address Line | 308 E MAIN ST
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City | WATERFORD
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State | WI
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Zip | 53185-4306
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Country | US
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Telephone | 262-923-3777
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Fax |
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Authorized Official
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Title or Position | ADULT NURSE PRACTIONER
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Name | MRS. TATJANA STEVANOVIC
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Credential | NP
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Telephone | 262-923-3777
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | 52D1037628
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License Number State | WI
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