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General NPI Number Information
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NPI Number | 1891106092
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Entity Type | Organization
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Legal Business Name | WISCONSIN WELLNESS CLINIC
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Dates
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Enumeration Date | 05/11/2014
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Last Update Date | 05/11/2014
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Provider Practice Location Address
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Address Line | 280 REGENCY CT SUITE 100
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City | BROOKFIELD
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State | WI
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Zip | 53045-6165
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Country | US
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Telephone | 262-373-9181
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Fax |
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Provider Business Mailing Address
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Address Line | 280 REGENCY CT SUITE 100
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City | BROOKFIELD
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State | WI
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Zip | 53045-6165
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | LISA MCNEIL
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Credential |
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Telephone | 262-373-9181
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State | WI
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