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General NPI Number Information
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NPI Number | 1417370602
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Entity Type | Organization
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Legal Business Name | REISWIG AESTHETICS SC
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Dates
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Enumeration Date | 01/24/2014
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Last Update Date | 04/03/2014
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Provider Practice Location Address
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Address Line | 1233 N MAYFAIR RD STE 208
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City | WAUWATOSA
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State | WI
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Zip | 53226-3255
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Country | US
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Telephone | 414-526-1291
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Fax |
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Provider Business Mailing Address
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Address Line | 1233 N MAYFAIR RD STE 208
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City | WAUWATOSA
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State | WI
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Zip | 53226-3255
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Country | US
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Telephone | 414-526-1291
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Fax |
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Authorized Official
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Title or Position | OWNER/PHYSICIAN
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Name | DR. AMANDA REISWIG
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Credential | M.D.
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Telephone | 414-526-1291
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 52720-20
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License Number State | WI
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