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General NPI Number Information
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NPI Number | 1477981942
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Entity Type | Organization
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Legal Business Name | SPECTRUM HEALTH MEDICAL CLINIC, LLC
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Dates
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Enumeration Date | 10/21/2013
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Last Update Date | 03/13/2014
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Provider Practice Location Address
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Address Line | W176N9830 RIVERCREST DR SUITE 102
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City | GERMANTOWN
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State | WI
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Zip | 53022-4625
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Country | US
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Telephone | 414-324-0944
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Fax | 414-921-5600
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Provider Business Mailing Address
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Address Line | PO BOX 639
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City | THIENSVILLE
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State | WI
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Zip | 53092-0639
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Country | US
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Telephone | 414-247-9005
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Fax | 414-247-9004
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | JOSEPH ALAN LOCKE
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Credential | DO
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Telephone | 414-324-0944
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 53594
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License Number State | WI
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