Provider Demographics
NPI:1154663904
Name:PAIN CENTERS OF WISCONSIN - WEST BEND, LLC
Entity Type:Organization
Organization Name:PAIN CENTERS OF WISCONSIN - WEST BEND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VISHAL
Authorized Official - Middle Name:
Authorized Official - Last Name:LAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-325-7246
Mailing Address - Street 1:4131 W LOOMIS RD
Mailing Address - Street 2:STE 300
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53221-2057
Mailing Address - Country:US
Mailing Address - Phone:414-325-7246
Mailing Address - Fax:414-325-3770
Practice Address - Street 1:1000 GATEWAY CT
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-8541
Practice Address - Country:US
Practice Address - Phone:414-325-7246
Practice Address - Fax:414-325-3770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-20
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical