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General NPI Number Information
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NPI Number | 1225153620
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Entity Type | Organization
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Legal Business Name | SOUTHEAST WISCONSIN AMBULATORY SURGICAL CENTER S C
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Dates
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Enumeration Date | 03/21/2007
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Last Update Date | 07/07/2014
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Provider Practice Location Address
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Address Line | 10105 74TH ST SUITE 102
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City | KENOSHA
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State | WI
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Zip | 53142-7519
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Country | US
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Telephone | 262-697-4301
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Fax | 262-925-8409
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Provider Business Mailing Address
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Address Line | 10105 74TH ST SUITE 102
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City | KENOSHA
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State | WI
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Zip | 53142-7519
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Country | US
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Telephone | 262-697-4301
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Fax | 262-925-8409
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Authorized Official
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Title or Position | OWNER
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Name | CYNTHIA R CERNAK
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Credential | DPM
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Telephone | 262-697-4301
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 52D1008619
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License Number State | WI
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