1225194186 NPI number — THE PRICE DECKER CLINIC

Table of content: (NPI 1225194186)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225194186 NPI number — THE PRICE DECKER CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE PRICE DECKER CLINIC
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:
Provider Other Organization Name Type Code:
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:
1225194186
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2905 ROLLINGWOOD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RHINELANDER
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54501-9187
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-282-6107
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21 S BROWN ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
RHINELANDER
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54501-3450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-362-5437
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PRICE DECKER
Authorized Official First Name:
THERESA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER THERAPIST
Authorized Official Telephone Number:
715-362-5437

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  2780-125 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 101YM0800X , with the licence number: 3361-125 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 101YM0800X , with the licence number: 2170-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 101YM0800X , with the licence number: 2124-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 103T00000X , with the licence number: 35255-020 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 32064800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 570412 . This is a "VALUE OPTIONS INSURANCE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 142406 . This is a "VALUE OPTIONS INSURANCE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 342442 . This is a "VALUE OPTIONS INSURANCE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 39283400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 42236600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 561257 . This is a "VALUE OPTIONS INSURANCE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 348018 . This is a "MHN INSURANCE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 561255 . This is a "VALUE OPTIONS INSURANCE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 122790 . This is a "MHN INSURANCE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 39193600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 39782000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 348019 . This is a "MHN INSURANCE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 201110 . This is a "MHN INSRUANCE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 40977100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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