Provider Demographics
NPI:1629217062
Name:RELIV OF SOUTHERN WISCONSIN
Entity type:Organization
Organization Name:RELIV OF SOUTHERN WISCONSIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN VP NUTRITION
Authorized Official - Prefix:MR
Authorized Official - First Name:VITTORIO
Authorized Official - Middle Name:GIUSEPPE
Authorized Official - Last Name:SPADARO
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:920-356-0681
Mailing Address - Street 1:305 S CLARK ST
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53050-1488
Mailing Address - Country:US
Mailing Address - Phone:920-356-0681
Mailing Address - Fax:
Practice Address - Street 1:201 PRAIRIE VIEW DR
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3406
Practice Address - Country:US
Practice Address - Phone:920-356-0681
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-09
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health