1073780961 NPI number — CENTER FOR LIFE & LOSS INTEGRATION

Table of content: (NPI 1073780961)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073780961 NPI number — CENTER FOR LIFE & LOSS INTEGRATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTER FOR LIFE & LOSS INTEGRATION
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:
1073780961
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4123 MONONA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONONA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53716-1661
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-258-7771
Provider Business Mailing Address Fax Number:
608-832-6486

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4123 MONONA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONONA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53716-1661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-258-7771
Provider Business Practice Location Address Fax Number:
608-832-6486
Provider Enumeration Date:
05/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KOEPPL
Authorized Official First Name:
JUDITH
Authorized Official Middle Name:
F.
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
608-258-7771

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  1842123 , 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: 42245700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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