Basic Information
| Provider Information | |||||||||
| NPI: | 1124328232 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST BEND CLINIC, INC. | ||||||||
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| OtherOrganizationName: | FROEDTERT HEALTH REHABILITATION AND SPORTS MEDICINE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 W PARADISE DR | ||||||||
| Address2: | |||||||||
| City: | WEST BEND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623343451 | ||||||||
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| Practice Location | |||||||||
| Address1: | W227 N16857 TILLIE LAKE COURT | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530379000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623656170 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2010 | ||||||||
| LastUpdateDate: | 10/25/2010 | ||||||||
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| AuthorizedOfficialLastName: | BROWNE | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2623066536 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.