Provider Demographics
NPI:1104042902
Name:WISCONSIN CENTER FOR MYOFASCIAL RELEASE, SC
Entity Type:Organization
Organization Name:WISCONSIN CENTER FOR MYOFASCIAL RELEASE, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:LINDA
Authorized Official - Last Name:HORSWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-652-1111
Mailing Address - Street 1:4103 60TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-2509
Mailing Address - Country:US
Mailing Address - Phone:262-652-1111
Mailing Address - Fax:262-652-1124
Practice Address - Street 1:4103 60TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-2509
Practice Address - Country:US
Practice Address - Phone:262-652-1111
Practice Address - Fax:262-652-1124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3534-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41012800Medicaid
WI41012800Medicaid