Provider Demographics
NPI:1346803632
Name:PAIN CENTERS OF WISCONSIN - SAUK PRAIRIE, LLC
Entity Type:Organization
Organization Name:PAIN CENTERS OF WISCONSIN - SAUK PRAIRIE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:BUNKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-325-3744
Mailing Address - Street 1:4131 W LOOMIS RD STE 300
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53221-2059
Mailing Address - Country:US
Mailing Address - Phone:414-325-7246
Mailing Address - Fax:414-325-3770
Practice Address - Street 1:250 26TH ST STE 1140
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU SAC
Practice Address - State:WI
Practice Address - Zip Code:53578-2204
Practice Address - Country:US
Practice Address - Phone:414-325-7246
Practice Address - Fax:414-325-3770
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:APM WISCONSIN MSO, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-04-22
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies