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General NPI Number Information
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NPI Number | 1467561506
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Entity Type | Organization
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Legal Business Name | SPINE CENTER OF WISCONSIN SC
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Dates
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Enumeration Date | 08/30/2006
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Last Update Date | 09/18/2008
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Provider Practice Location Address
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Address Line | 2801 W KINNICKINNIC RIVER PKWY STE 355
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City | MILWAUKEE
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State | WI
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Zip | 53215-3695
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Country | US
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Telephone | 414-235-3623
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Fax | 414-235-3623
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Provider Business Mailing Address
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Address Line | PO BOX 320695
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City | FRANKLIN
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State | WI
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Zip | 53132
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Country | US
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Telephone | 414-235-3623
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Fax | 414-235-3623
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Authorized Official
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Title or Position | OFC MGR
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Name | MS. MARY J BANACH
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Credential |
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Telephone | 414-235-3623
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0200X
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Taxonomy Name | Radiology Clinic/Center
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License Number | XM39276
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 19042
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License Number State | WI
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