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NPI 1689666596 MENOMONEE FALLS AMBULATORY SURGERY CENTER

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					                                                                                                                                                   HIPAASpace NPI Form
WWW.HIPAASPACE.COM                                                                                                                                    Source NPI Lookup


                              NATIONAL PROVIDER IDENTIFIER (NPI) FORM
Information provided in the current document is obtained from official source and accuracy of the information provided is the sole
responsibility of the healthcare provide. All changes, corrections or updates must be done through the official sources. Please contact
HIPAASpace.com in case you need the assistance in obtaining the official contacts of corresponding government organizations.

SECTION 1 – BASIC INFORMATION
 NPI Number          Provider (Organization) Full Name                  Provider (Organization) Other Name                         Entity Type          Replacement NPI

 1689666596 MENOMONEE FALLS AMBULATORY SURGERY CENTER                                                                              Organization
 Gender        Enumeration Date     Last Update Date     Deactivation Reason Code      Deactivation Date       Reactivation Date    Employer Identification Number (EIN)

               08/17/2005           07/08/2007

SECTION 2 – CONTACT INFORMATION
 Business Mailing Address

 W180N8045 TOWN HALL RD , MENOMONEE FALLS WI530513518-530513518 US
 Practice Location Address

 W180N8045 TOWN HALL RD , MENOMONEE FALLS WI530513518-530513518 US
 Business Phone Number                       Business Fax Number                            Practice Phone Number                            Practice Fax Number

 2622500950                                  2622500955                                     2622500950                                       2622500955
 Authorized Official – Name                                                         Authorized Official – Title/Position              Authorized Official - Phone Number

 WALLACE DIANNE                                                                     EXECUTIVE DIRECTOR                                2622500950

SECTION 3 – LICENSING, IDENTIFICATION INFORMATION

A. TAXONOMY INFORMATION

1. Code: 261QA1903X (Ambulatory Surgical). WI.




B. OTHER PROVIDER IDENTIFIERS

1. Identifier: 41907900. Type: MEDICAID. WI.




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