Provider Demographics
NPI:1093089161
Name:OZAUKEE CRANIAL CLINIC, LLC
Entity Type:Organization
Organization Name:OZAUKEE CRANIAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KESTEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:262-241-1133
Mailing Address - Street 1:1476 W MEQUON RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3268
Mailing Address - Country:US
Mailing Address - Phone:262-241-1133
Mailing Address - Fax:
Practice Address - Street 1:1476 W MEQUON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3268
Practice Address - Country:US
Practice Address - Phone:262-241-1133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2178-24261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy