Facts
- Status
- A
- Type
- Individual
- Enumeration date
- 2024-09-03
- Last updated
- 2024-09-03
Specialties
Licenses
- License WI
- 1116116
Location
- Practice location
- 3789 SUNNY WOOD DR
- City
- DEFOREST WI
- Postal code
- 535322852
- Phone
- 608-630-5889
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
The OIG NPI list is not in this build yet. Confirm on OIG's search.
Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.