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Organization
SPINE CENTER OF WISCONSIN SC
Active
Organization
SPINE CENTER OF WISCONSIN SC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. MARY J BANACH (OFC MGR)
(414) 235-3623
Entity
Organization
Contact information
Practice address
2801 W KINNICKINNIC RIVER PKWY STE 355, MILWAUKEE, WI 53215-3695
(414) 235-3623
(414) 235-3623
Mailing address
PO BOX 320695, FRANKLIN, WI 53132
(414) 235-3623
(414) 235-3623
Taxonomy
Speciality
Code
Description
License number
State
261QM2500X
Medical Specialty Clinic/Center
Primary
19042
WI
261QR0200X
Radiology Clinic/Center
XM39276
WI
332B00000X
Durable Medical Equipment & Medical Supplies
—
NULL
Other
Enumeration date
08/30/2006
Last updated
09/18/2008
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