MEDICARE: ALLERGY & ASTHMA CLINIC OF KENOSHA SC

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	261QM2500X	Medical Specialty Clinic/Center		WI

General Provider Information

NPI Number	:	1093747586
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALLERGY & ASTHMA CLINIC OF KENOSHA SC

Provider Business Mailing Address
First Line	:	5200 WASHINGTON AVE
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53406-4238
Country	:	US
Telephone Number	:	262-632-5151
Fax Number	:	262-632-6151

Provider Business Practice Location Address
First Line	:	5200 WASHINGTON AVE
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53406-4238
Country	:	US
Telephone Number	:	262-632-5151
Fax Number	:	262-632-6151

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KULWANT SINGH DHALIWAL
Credential	:	MD
Telephone Number	:	262-632-5151

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	11/01/2007

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