1699613364 NPI number — MR. ANTHONY A. GROOTHOFF SAC-IT

Table of content: MR. ANTHONY A. GROOTHOFF SAC-IT (NPI 1699613364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699613364 NPI number — MR. ANTHONY A. GROOTHOFF SAC-IT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROOTHOFF
Provider First Name:
ANTHONY
Provider Middle Name:
A.
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
SAC-IT
Provider Gender Code:
M

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:
1699613364
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
533 PEACE PIPE ROAD, PO BOX 189
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAC DU FLAMBEAU
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54538-0189
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-588-1511
Provider Business Mailing Address Fax Number:
715-588-3903

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PO BOX 189
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAC DU FLAMBEAU
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54538-0189
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-588-1511
Provider Business Practice Location Address Fax Number:
715-588-3903
Provider Enumeration Date:
03/24/2026

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  21115-130 , 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)





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