1437471448 NPI number — OPTIONS FOR INDEPENDENT LIVING

Table of content: (NPI 1437471448)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437471448 NPI number — OPTIONS FOR INDEPENDENT LIVING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTIONS FOR INDEPENDENT LIVING
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:
1437471448
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 COUNTRY CLUB RD
Provider Second Line Business Mailing Address:
PO BOX 11967
Provider Business Mailing Address City Name:
GREEN BAY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54313-4908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-490-8270
Provider Business Mailing Address Fax Number:
920-490-0700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 COUNTRY CLUB RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREEN BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54313-4908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-490-8270
Provider Business Practice Location Address Fax Number:
920-490-0700
Provider Enumeration Date:
02/17/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BARRY
Authorized Official First Name:
KATHRYN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
ASSISTANT DIRECTOR
Authorized Official Telephone Number:
920-490-8270

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X , with the licence number:  100003331 , 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: 100003331 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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