1073739165 NPI number — CITY OF MELLEN

Table of content: (NPI 1073739165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073739165 NPI number — CITY OF MELLEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF MELLEN
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:
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:
1073739165
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 EAST BENNETT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELLEN
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-274-2136
Provider Business Mailing Address Fax Number:
715-274-3707

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 EAST BENNETT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELLEN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-274-2136
Provider Business Practice Location Address Fax Number:
715-274-3707
Provider Enumeration Date:
04/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SCRIBNER
Authorized Official First Name:
BECKY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
DEPUTY CLERK-TREASURER
Authorized Official Telephone Number:
715-274-2136

Provider Taxonomy Codes

  • Taxonomy code: 146N00000X , with the licence number:  6000118 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3416L0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 41333800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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