1306965033 NPI number — NORTHWEST JOURNEY - ELLSWORTH

Table of content: (NPI 1306965033)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306965033 NPI number — NORTHWEST JOURNEY - ELLSWORTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST JOURNEY - ELLSWORTH
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:
1306965033
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
N6096 530TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLSWORTH
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54011-5107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-273-0203
Provider Business Mailing Address Fax Number:
715-273-0344

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
N6096 530TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELLSWORTH
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54011-5107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-273-0203
Provider Business Practice Location Address Fax Number:
715-273-0344
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KALAMBOKIDIS
Authorized Official First Name:
NICK
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
715-327-4402

Provider Taxonomy Codes

  • Taxonomy code: 261QM0855X , with the licence number:  2326 , 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: 43006700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7H956NO . This is a "BCBS OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 42626 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1306965033 . This is a "HUMANA" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 85575 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1306965033 . This is a "VALUE OPTIONS" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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