Provider Demographics
NPI:1356520563
Name:BOUC FAMILY WELLNESS CENTER, LLC
Entity type:Organization
Organization Name:BOUC FAMILY WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:T
Authorized Official - Last Name:BOUC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:608-365-7200
Mailing Address - Street 1:3005 RIVERSIDE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1500
Mailing Address - Country:US
Mailing Address - Phone:608-365-7200
Mailing Address - Fax:608-365-7202
Practice Address - Street 1:3005 RIVERSIDE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-1500
Practice Address - Country:US
Practice Address - Phone:608-365-7200
Practice Address - Fax:608-365-7202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36893207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32161500Medicaid
WI000054295Medicare PIN
WIG14701Medicare UPIN