1740327618 NPI number — WENDY P GOLDBACH OTD MED OTR CHT

Table of content: ARSELAINE DANIELLE AUGUSTIN I (NPI 1174168140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740327618 NPI number — WENDY P GOLDBACH OTD MED OTR CHT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLDBACH
Provider First Name:
WENDY
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTD MED OTR CHT
Provider Gender Code:
F

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:
1740327618
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2704 BIBLE CAMP RD
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
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-490-2954
Provider Business Mailing Address Fax Number:
715-282-7161

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12800 N LAKE SHORE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEQUON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53097-2418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-243-4261
Provider Business Practice Location Address Fax Number:
262-243-4261
Provider Enumeration Date:
01/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XH1200X , with the licence number:  1092026 , 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)

  • Identifier: 1780663013 . This is a "NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 40547700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1092-26 . This is a "WISCONSIN STATE LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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