1598890378 NPI number — LAC COURTE OREILLES GOVERNING BOARD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598890378 NPI number — LAC COURTE OREILLES GOVERNING BOARD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAC COURTE OREILLES GOVERNING BOARD
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:
LAC COURTE OREILLES COMMUNITY HEALTH CENTE
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:
1598890378
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13394 W TREPANIA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAYWARD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54843-2186
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-638-5100
Provider Business Mailing Address Fax Number:
715-634-6107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13394 W TREPANIA RD
Provider Second Line Business Practice Location Address:
LAC COURTE OREILLES GOVERNING BOARD
Provider Business Practice Location Address City Name:
HAYWARD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54843-2186
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-634-5100
Provider Business Practice Location Address Fax Number:
715-634-6107
Provider Enumeration Date:
02/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BAKER
Authorized Official First Name:
RAE
Authorized Official Middle Name:
E
Authorized Official Title or Position:
THIRD-PARTY BILLING
Authorized Official Telephone Number:
715-638-5169

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5119044 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 32956000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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