1679572788 NPI number — SOUTHWESTERN WI COMMUNITY ACTION PROGRAM, INC

Table of content: (NPI 1679572788)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679572788 NPI number — SOUTHWESTERN WI COMMUNITY ACTION PROGRAM, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWESTERN WI COMMUNITY ACTION PROGRAM, INC
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:
SWCAP NEIGHBORHOOD HEALTH PARTNERS
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:
1679572788
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 704
Provider Second Line Business Mailing Address:
275 W MAIN ST
Provider Business Mailing Address City Name:
PLATTEVILLE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53818-0704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-348-9766
Provider Business Mailing Address Fax Number:
608-348-3915

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
275 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLATTEVILLE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53818-3110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-348-9766
Provider Business Practice Location Address Fax Number:
608-348-3915
Provider Enumeration Date:
07/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BODDEN
Authorized Official First Name:
JACQUELYNE
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
PROGRAM DIRECTOR/NURSE PRACTITIONER
Authorized Official Telephone Number:
608-348-9766

Provider Taxonomy Codes

  • Taxonomy code: 261QA0005X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0050X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 44008100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 42005400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 41863200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 43973600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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