Basic Information
| Provider Information | |||||||||
| NPI: | 1356904254 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAIN CENTERS OF WISCONSIN - BEAVER DAM, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4131 W LOOMIS RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532212059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143257246 | ||||||||
| FaxNumber: | 4143253770 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 N SPRING ST | ||||||||
| Address2: | |||||||||
| City: | BEAVER DAM | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539161178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143257246 | ||||||||
| FaxNumber: | 4143253770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2019 | ||||||||
| LastUpdateDate: | 04/16/2019 | ||||||||
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| AuthorizedOfficialLastName: | LAL | ||||||||
| AuthorizedOfficialFirstName: | VISHAL | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED REPRESENTATIVE | ||||||||
| AuthorizedOfficialTelephone: | 4143257246 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | APM WISCONSIN MSO, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.