1598149403 NPI number — JANESVILLE PSYCHIATRIC CLINIC OF MAIN

Table of content: (NPI 1598149403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598149403 NPI number — JANESVILLE PSYCHIATRIC CLINIC OF MAIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JANESVILLE PSYCHIATRIC CLINIC OF MAIN
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:
BC PSYCHIATRIC CLINIC
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:
1598149403
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2010 PARKSIDE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JANESVILLE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53548-6613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-436-6161
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2010 PARKSIDE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JANESVILLE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53548-6613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-436-6161
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/10/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HOLLINGSWORTH
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
608-436-6161

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  162 - 124, 366 - 125 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: 3044- 123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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