Provider Demographics
NPI:1275811861
Name:PIBCOA
Entity Type:Organization
Organization Name:PIBCOA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ELECTRO-TOXICOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-672-2000
Mailing Address - Street 1:1101 W CLAIREMONT AVE
Mailing Address - Street 2:UNIT 1G
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-4503
Mailing Address - Country:US
Mailing Address - Phone:715-672-2000
Mailing Address - Fax:715-672-3262
Practice Address - Street 1:1101 W CLAIREMONT AVE
Practice Address - Street 2:UNIT 1G
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4503
Practice Address - Country:US
Practice Address - Phone:715-672-2000
Practice Address - Fax:715-672-3262
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE PAIN, INJURY AND BRAIN CENTERS OF AMERICA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-29
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI123870-30261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain