=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538965660
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MA CLINICAL SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2025
-----------------------------------------------------
Last Update Date | 02/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5700 6TH AVE
-----------------------------------------------------
City | KENOSHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53140-4104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-997-9573
-----------------------------------------------------
Fax | 262-997-9574
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5700 6TH AVE
-----------------------------------------------------
City | KENOSHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53140-4104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-997-9573
-----------------------------------------------------
Fax | 262-997-9574
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ERIN MERRITT
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 262-997-9573
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2083B0002X
-----------------------------------------------------
Taxonomy Name | Obesity Medicine (Preventive Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------