MEDICARE: SPINE SOLUTIONS OF WEST BEND LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1073113841
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINE SOLUTIONS OF WEST BEND LLC

Provider Business Mailing Address
First Line	:	2124 KOHLER MEMORIAL DR
Second Line	:
City	:	SHEBOYGAN
State	:	WI
Zip	:	53081-3169
Country	:	US
Telephone Number	:	414-455-1153
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 GATEWAY CT STE 200
Second Line	:
City	:	WEST BEND
State	:	WI
Zip	:	53095-8541
Country	:	US
Telephone Number	:	414-455-1153
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JEREMY SCARLETT
Credential	:	MD
Telephone Number	:	414-455-1153

Provider Enumeration Date	:	10/29/2020
Last Update Date	:	10/29/2020

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