Provider Demographics
NPI:1962893842
Name:ALIGN CLINIC, LLC
Entity type:Organization
Organization Name:ALIGN CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:I
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:650-375-2231
Mailing Address - Street 1:445 CARDINAL LN STE 110
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-9587
Mailing Address - Country:US
Mailing Address - Phone:920-940-5277
Mailing Address - Fax:844-308-8462
Practice Address - Street 1:445 CARDINAL LN STE 110
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-9587
Practice Address - Country:US
Practice Address - Phone:920-940-5277
Practice Address - Fax:844-308-8462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100063956Medicaid