Provider Demographics
NPI:1124559406
Name:STILLWATERS CANCER SUPPORT CENTER
Entity Type:Organization
Organization Name:STILLWATERS CANCER SUPPORT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-524-4149
Mailing Address - Street 1:2607 N GRANDVIEW BLVD STE 108
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1690
Mailing Address - Country:US
Mailing Address - Phone:262-548-9148
Mailing Address - Fax:262-513-5731
Practice Address - Street 1:2607 N GRANDVIEW BLVD STE 108
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1690
Practice Address - Country:US
Practice Address - Phone:262-548-9148
Practice Address - Fax:262-513-5731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-27
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health