Provider Demographics
NPI:1639685779
Name:EDP OF WISCONSIN, SC
Entity Type:Organization
Organization Name:EDP OF WISCONSIN, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GARIBAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-736-8963
Mailing Address - Street 1:141 W JACKSON BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604-3048
Mailing Address - Country:US
Mailing Address - Phone:312-937-3619
Mailing Address - Fax:
Practice Address - Street 1:600 HARTBROOK DR STOP 7
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-1436
Practice Address - Country:US
Practice Address - Phone:262-367-0680
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-27
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental