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General NPI Number Information
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NPI Number | 1649218215
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Entity Type | Organization
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Legal Business Name | WILSON WELLNESS GROUP
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Dates
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Enumeration Date | 06/03/2006
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Last Update Date | 06/23/2008
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Provider Practice Location Address
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Address Line | 4625 SHERIDAN RD
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City | KENOSHA
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State | WI
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Zip | 53140-3323
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Country | US
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Telephone | 262-657-3333
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Fax | 262-657-6201
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Provider Business Mailing Address
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Address Line | 4625 SHERIDAN RD
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City | KENOSHA
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State | WI
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Zip | 53140-3323
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Country | US
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Telephone | 262-657-3333
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Fax | 262-657-6201
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Authorized Official
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Title or Position | PRESIDENT CEO
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Name | MR. LAWRENCE E BALKIN
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Credential |
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Telephone | 847-217-1976
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 5539340001
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License Number State | WI
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