# SPINE CENTER OF WISCONSIN SC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1467561506
- **Authorized official:** MS. MARY J BANACH (OFC MGR)
- **Authorized official phone:** (414) 235-3623

## Contact information

- **Practice address:** 2801 W KINNICKINNIC RIVER PKWY STE 355, MILWAUKEE, WI 53215-3695
- **Practice address phone:** (414) 235-3623
- **Practice address fax:** (414) 235-3623
- **Mailing address:** PO BOX 320695, FRANKLIN, WI 53132
- **Mailing address phone:** (414) 235-3623
- **Mailing address fax:** (414) 235-3623

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QM2500X | Medical Specialty Clinic/Center | 19042 | WI | Yes |
| 261QR0200X | Radiology Clinic/Center | XM39276 | WI | — |
| 332B00000X | Durable Medical Equipment & Medical Supplies | — | NULL | — |

## Other

- **Enumeration date:** 08/30/2006
- **Last updated:** 09/18/2008