Provider Demographics
NPI:1003132556
Name:WAUPACA WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:WAUPACA WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:CLEVE
Authorized Official - Last Name:HAMEL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-258-7444
Mailing Address - Street 1:1336 MICHIGAN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-1648
Mailing Address - Country:US
Mailing Address - Phone:715-258-7444
Mailing Address - Fax:715-258-7844
Practice Address - Street 1:1336 MICHIGAN ST
Practice Address - Street 2:SUITE A
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-1648
Practice Address - Country:US
Practice Address - Phone:715-258-7444
Practice Address - Fax:715-258-7844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-08
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3702-012261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center