| Organization Name: | PAIN CENTERS OF WISCONSIN - FORT ATKINSON, LLC |
| NPI Number: | 1316218167 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | VISHAL LAL (CEO) |
| Mailing Address: | 1604 Madison Ave Fort Atkinson |
| State: | WI US |
| Postal Code: | 535383101 |
| Phone Number: | 4143257246 |
| Fax Number: | 4143253770 |
| NPI Enumeration Date: | 01/25/2012 |
| NPI Last Update Date: | 01/25/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QA1903X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Ambulatory Surgical |
| Taxonomy Definition: | |