Provider Demographics
NPI:1922164656
Name:PROCARE MEDICAL GROUP SC
Entity Type:Organization
Organization Name:PROCARE MEDICAL GROUP SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROSALINA
Authorized Official - Middle Name:
Authorized Official - Last Name:VALLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-291-2624
Mailing Address - Street 1:3727 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-3182
Mailing Address - Country:US
Mailing Address - Phone:414-291-2626
Mailing Address - Fax:414-291-2630
Practice Address - Street 1:3727 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-3182
Practice Address - Country:US
Practice Address - Phone:414-291-2626
Practice Address - Fax:414-291-2630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32808100Medicaid