Provider Demographics
NPI:1508562323
Name:SUN PRAIRIE LASER PAIN CENTER
Entity Type:Organization
Organization Name:SUN PRAIRIE LASER PAIN CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:SIMONS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-860-6426
Mailing Address - Street 1:830 20TH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU SAC
Mailing Address - State:WI
Mailing Address - Zip Code:53578-2102
Mailing Address - Country:US
Mailing Address - Phone:920-860-6426
Mailing Address - Fax:
Practice Address - Street 1:414 W MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-2912
Practice Address - Country:US
Practice Address - Phone:920-860-6426
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty