Provider Demographics
NPI:1104913623
Name:PREMIER PHYSICAL MEDICINE AND WELLNESS CLINIC
Entity type:Organization
Organization Name:PREMIER PHYSICAL MEDICINE AND WELLNESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:MULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:715-356-9999
Mailing Address - Street 1:PO BOX 1550
Mailing Address - Street 2:
Mailing Address - City:WOODRUFF
Mailing Address - State:WI
Mailing Address - Zip Code:54568-1550
Mailing Address - Country:US
Mailing Address - Phone:715-356-9999
Mailing Address - Fax:715-356-9894
Practice Address - Street 1:1446 1ST AVE
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:WI
Practice Address - Zip Code:54568-9149
Practice Address - Country:US
Practice Address - Phone:715-356-9999
Practice Address - Fax:715-356-9894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33657208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21307000Medicaid
WI21307000Medicaid
WIF37495Medicare UPIN