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General NPI Number Information
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NPI Number | 1851887715
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Entity Type | Organization
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Legal Business Name | SOUTHERN LAKES ENDOSCOPY LLC
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Dates
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Enumeration Date | 07/03/2018
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Last Update Date | 01/08/2025
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Provider Practice Location Address
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Address Line | 240 MAPLE AVE STE 2220
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City | MUKWONAGO
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State | WI
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Zip | 53149-8475
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Country | US
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Telephone | 414-454-0600
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Fax | 414-454-0971
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Provider Business Mailing Address
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Address Line | 2801 W KINNICKINNIC RIVER PKWY STE 1080
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City | MILWAUKEE
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State | WI
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Zip | 53215-3689
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Country | US
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Telephone | 414-908-6506
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Fax | 414-908-6510
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Authorized Official
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Title or Position | DIRECTOR REVENUE CYCLE MANAGEMENT
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Name | AMY JO BURNS
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Credential |
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Telephone | 262-970-7825
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State |
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