Provider Demographics
NPI:1457861007
Name:INTERGRATED PAIN AND SPINE CARE SC
Entity Type:Organization
Organization Name:INTERGRATED PAIN AND SPINE CARE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-967-9000
Mailing Address - Street 1:PO BOX 170181
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-8016
Mailing Address - Country:US
Mailing Address - Phone:414-967-9000
Mailing Address - Fax:414-332-3712
Practice Address - Street 1:5261 N PORT WASHINGTON RD STE 100
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217-4903
Practice Address - Country:US
Practice Address - Phone:414-967-9000
Practice Address - Fax:414-332-3712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-10
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3812-012111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI=========OtherTIN