Provider Demographics
NPI:1033130927
Name:MEDICAL ACUPUNCTURE & PAIN CLINIC SC
Entity Type:Organization
Organization Name:MEDICAL ACUPUNCTURE & PAIN CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:VEGAFRIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-335-8025
Mailing Address - Street 1:422 MEADOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53090-2416
Mailing Address - Country:US
Mailing Address - Phone:262-335-8025
Mailing Address - Fax:
Practice Address - Street 1:422 MEADOWBROOK DR
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53090-2416
Practice Address - Country:US
Practice Address - Phone:262-335-8025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31208800Medicaid
WI31208800Medicaid
WI000001577Medicare PIN