| NPI | 1154712271 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TANYA MAULDIN Provider Enrollment Manger 414-225-1611 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261Q00000X Clinic/Center |
| Additional Taxonomies | 261QH0100X Clinic/Center, Health Services |
| 207Q00000X Family Medicine | |
| Enumeration Date | 2015-02-11 |
| Last Update Date | 2025-09-08 |