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General NPI Number Information
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NPI Number | 1225296874
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Entity Type | Organization
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Legal Business Name | INTEGRATED SPORT AND SPINE CLINIC OF MADISON LLC
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Dates
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Enumeration Date | 05/30/2008
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Last Update Date | 05/30/2008
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Provider Practice Location Address
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Address Line | 3109 COMMERCIAL AVE
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City | MADISON
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State | WI
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Zip | 53714-1447
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Country | US
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Telephone | 608-271-8009
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Fax | 608-243-9290
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Provider Business Mailing Address
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Address Line | 3109 COMMERCIAL AVE
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City | MADISON
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State | WI
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Zip | 53714-1447
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Country | US
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Telephone | 608-271-8009
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Fax | 608-243-9290
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Authorized Official
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Title or Position | OWNER
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Name | DAVID HEITMANN
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Credential | DC, MS
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Telephone | 608-271-8009
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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 | 4401-12
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License Number State | WI
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