Provider Demographics
NPI:1407152945
Name:PAIN CENTERS OF WISCONSIN - KENOSHA, LLC
Entity Type:Organization
Organization Name:PAIN CENTERS OF WISCONSIN - KENOSHA, 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 1:9697 SAINT CATHERINES DR
Mailing Address - Street 2:STE 102
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-2118
Mailing Address - Country:US
Mailing Address - Phone:414-325-7246
Mailing Address - Fax:
Practice Address - Street 1:9697 SAINT CATHERINES DR
Practice Address - Street 2:STE 102
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-2118
Practice Address - Country:US
Practice Address - Phone:414-325-7246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-01
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical