Provider Demographics
NPI:1750412201
Name:PAIN MANAGEMENT & TREATMENT CENTER, S.C.
Entity type:Organization
Organization Name:PAIN MANAGEMENT & TREATMENT CENTER, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ECCLESTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-354-0772
Mailing Address - Street 1:8901 N 76TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53223-1901
Mailing Address - Country:US
Mailing Address - Phone:414-354-0772
Mailing Address - Fax:414-365-0773
Practice Address - Street 1:8901 N 76TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-1901
Practice Address - Country:US
Practice Address - Phone:414-354-0772
Practice Address - Fax:414-365-0773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32896100Medicaid