1073526661 NPI number — GUNDERSEN CLINIC LTD

Table of content: (NPI 1073526661)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073526661 NPI number — GUNDERSEN CLINIC LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GUNDERSEN CLINIC LTD
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:
GUNDERSEN PHARMACY - LA CROSSE CLINIC
Provider Other Organization Name Type Code:
5
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:
1073526661
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1836 SOUTH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA CROSSE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54601-5429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-775-5595
Provider Business Mailing Address Fax Number:
608-775-4445

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1836 SOUTH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA CROSSE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54601-5429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-775-5595
Provider Business Practice Location Address Fax Number:
608-775-4445
Provider Enumeration Date:
08/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CARRELL
Authorized Official First Name:
LOREN
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATIVE DIRECTOR
Authorized Official Telephone Number:
608-775-6369

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  4884 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0002X , with the licence number: 263208 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2112770 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 33096300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com