1013069624 NPI number — NORTHREACH HEALTHCARE, LLC

Table of content: (NPI 1013069624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013069624 NPI number — NORTHREACH HEALTHCARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHREACH HEALTHCARE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CRIVITZ MEDICAL CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013069624
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 22487
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREEN BAY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54305-2487
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-445-7226
Provider Business Mailing Address Fax Number:
920-445-7229

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
218 S HWY 141
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRIVITZ
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54114-1677
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-854-7477
Provider Business Practice Location Address Fax Number:
715-854-7785
Provider Enumeration Date:
01/17/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HIPKE
Authorized Official First Name:
CAROL
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF BUSINESS SERVICES
Authorized Official Telephone Number:
715-732-2078

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 291U00000X , with the licence number: 52D0394395 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 52D0394395 . This is a "CLINIC CLIA" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 4825080007 . This is a "MEDICARE DME" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".