Provider Demographics
NPI:1124495932
Name:WATERTOWN MEDICAL CENTER LLC
Entity type:Organization
Organization Name:WATERTOWN MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHNETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-596-6063
Mailing Address - Street 1:680 S 4TH ST # KH-3
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-2407
Mailing Address - Country:US
Mailing Address - Phone:502-596-6063
Mailing Address - Fax:
Practice Address - Street 1:125 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3303
Practice Address - Country:US
Practice Address - Phone:920-262-4210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-27
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty