MEDICARE: PAIN CENTERS OF WISCONSIN - 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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1407419328
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAIN CENTERS OF WISCONSIN - WEST BEND, LLC

Provider Business Mailing Address
First Line	:	4131 W LOOMIS RD STE 300
Second Line	:
City	:	GREENFIELD
State	:	WI
Zip	:	53221-2059
Country	:	US
Telephone Number	:	414-325-7246
Fax Number	:	414-325-3770

Provider Business Practice Location Address
First Line	:	1000 GATEWAY CT
Second Line	:
City	:	WEST BEND
State	:	WI
Zip	:	53095-8541
Country	:	US
Telephone Number	:	414-325-7246
Fax Number	:	414-325-3770

Authorized Official
Title or Position	:	AUTHORIZED REPRESENTATIVE
Name	:	VISHAL LAL
Credential	:
Telephone Number	:	414-325-7246

Provider Enumeration Date	:	04/16/2019
Last Update Date	:	04/16/2019

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