Provider Demographics
NPI:1073711503
Name:ARC OF LIFE MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:ARC OF LIFE MEDICAL CENTER LLC
Other - Org Name:ARC OF LIFE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER / PARTIAL OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAILI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:RICHEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-441-3455
Mailing Address - Street 1:648 S GAMMON RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1370
Mailing Address - Country:US
Mailing Address - Phone:608-441-3455
Mailing Address - Fax:
Practice Address - Street 1:648 S GAMMON RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1370
Practice Address - Country:US
Practice Address - Phone:608-441-3455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2023-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38734300Medicaid