Provider Demographics
NPI:1033820386
Name:CARBON HEALTH PRIMARY CARE OF WISCONSIN SC
Entity type:Organization
Organization Name:CARBON HEALTH PRIMARY CARE OF WISCONSIN SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KAITLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOYLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-601-5392
Mailing Address - Street 1:2100 FRANKLIN ST STE 355
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-3140
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11415 W BURLEIGH ST STE 103
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-3217
Practice Address - Country:US
Practice Address - Phone:415-446-1733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-07
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care