1063685071 NPI number — CITY OF WATERTOWN

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 1063685071 NPI number — CITY OF WATERTOWN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF WATERTOWN
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:
WATERTOWN DEPARTMENT OF PUBLIC HEALTH
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:
1063685071
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
515 S 1ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERTOWN
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53094-4409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-262-8090
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
515 S 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERTOWN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53094-4409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-262-8090
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
QUEST
Authorized Official First Name:
CAROL
Authorized Official Middle Name:
FRANCES
Authorized Official Title or Position:
HEALTH OFFICER/DIRECTOR
Authorized Official Telephone Number:
920-262-8090

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 44002500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 41855200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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