1689670549 NPI number — WOODLANDS OF GILLETT, INC.

Table of content: (NPI 1689670549)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689670549 NPI number — WOODLANDS OF GILLETT, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOODLANDS OF GILLETT, INC.
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:
1689670549
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
430 MANOR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SURING
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54174-9182
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-842-1111
Provider Business Mailing Address Fax Number:
920-842-1153

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 ROBIN HOOD LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GILLETT
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54124-9201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-855-2136
Provider Business Practice Location Address Fax Number:
920-855-1631
Provider Enumeration Date:
06/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SCHNEIDER
Authorized Official First Name:
SANDI
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
920-855-2136

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  2702 , 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: 20188500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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