1588158679 NPI number — HOPE ROAD WELLNESS CENTER, LLC

Table of content: (NPI 1588158679)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588158679 NPI number — HOPE ROAD WELLNESS CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOPE ROAD WELLNESS CENTER, LLC
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:
1588158679
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 383
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREDERIC
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54837-0383
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-869-6484
Provider Business Mailing Address Fax Number:
800-684-2131

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 HOPE ROAD WEST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREDERIC
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54837-0383
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-491-5365
Provider Business Practice Location Address Fax Number:
800-684-2131
Provider Enumeration Date:
06/21/2018

Additional Information

Authorized Official

Authorized Official Last Name:
THOMPSON
Authorized Official First Name:
KRISTINA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
MENTAL HEALTH CLINICIAN
Authorized Official Telephone Number:
715-491-5365

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  8287 , 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: 1689004426 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com