MEDICARE: INVIVO WELLNESS RESTORATION, 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	174400000X	Specialist	4778-024	WI

General Provider Information

NPI Number	:	1427061027
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INVIVO WELLNESS RESTORATION, LLC

Provider Business Mailing Address
First Line	:	2060 N HUMBOLDT BLVD
Second Line	:	SUITE 300
City	:	MILWAUKEE
State	:	WI
Zip	:	53212-3504
Country	:	US
Telephone Number	:	414-265-5606
Fax Number	:	414-265-5649

Provider Business Practice Location Address
First Line	:	2060 N HUMBOLDT BLVD
Second Line	:	SUITE 300
City	:	MILWAUKEE
State	:	WI
Zip	:	53212-3504
Country	:	US
Telephone Number	:	414-265-5606
Fax Number	:	414-265-5649

Authorized Official
Title or Position	:	PT/CO-OWNER
Name	:	ANN MARIE HESSIL
Credential	:
Telephone Number	:	414-265-5606

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	03/11/2008

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