MEDICARE: CONSULTANTS LABORATORY OF WISCONSIN, 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	291U00000X	Clinical Medical Laboratory

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	52D0397671	OTHER	WI	CLIAA

General Provider Information

NPI Number	:	1912049016
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONSULTANTS LABORATORY OF WISCONSIN, LLC

Provider Business Mailing Address
First Line	:	430 E DIVISION ST
Second Line	:
City	:	FOND DU LAC
State	:	WI
Zip	:	54935-4560
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	723 PARK RIDGE LN
Second Line	:
City	:	NORTH FOND DU LAC
State	:	WI
Zip	:	54937-1385
Country	:	US
Telephone Number	:	920-926-8610
Fax Number	:

Authorized Official
Title or Position	:	PATIENT ACCOUNTS SUPERVISOR
Name	:	MS. DEBORAH CHRISTIAN
Credential	:
Telephone Number	:	920-926-5840

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	12/16/2022

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