Provider Demographics
NPI:1730909664
Name:EC LASER AND SURGERY INSTITUTE OF WI, LLC
Entity type:Organization
Organization Name:EC LASER AND SURGERY INSTITUTE OF WI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GODDARD
Authorized Official - Suffix:
Authorized Official - Credentials:COO
Authorized Official - Phone:715-261-8557
Mailing Address - Street 1:800 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-4754
Mailing Address - Country:US
Mailing Address - Phone:715-261-8500
Mailing Address - Fax:
Practice Address - Street 1:3301 STANLEY ST
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-1323
Practice Address - Country:US
Practice Address - Phone:715-298-5500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EC LASER AND SURGERY INSTITUTE OF WI, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical