Basic Information
| Provider Information | |||||||||
| NPI: | 1497106900 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEALTHSTAT ONSITE CLINIC WATERTOWN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4651 CHARLOTTE PARK DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282171956 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 DODGE ST | ||||||||
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| City: | WATERTOWN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530944434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049365546 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2016 | ||||||||
| LastUpdateDate: | 06/27/2016 | ||||||||
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| AuthorizedOfficialLastName: | HUTTON | ||||||||
| AuthorizedOfficialFirstName: | WARREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 7045296161 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083P0500X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Preventive Medicine/Occupational Environmental Medicine |
No ID Information.