1881024404 NPI number — FENNIMORE HEALING ARTS, LLC

Table of content: (NPI 1881024404)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881024404 NPI number — FENNIMORE HEALING ARTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FENNIMORE HEALING ARTS, 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:
1881024404
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
770 LINCOLN AVE
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
FENNIMORE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53809-1562
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-572-3494
Provider Business Mailing Address Fax Number:
608-822-3812

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
770 LINCOLN AVE
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
FENNIMORE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53809-1562
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-572-3494
Provider Business Practice Location Address Fax Number:
608-822-3812
Provider Enumeration Date:
11/18/2013

Additional Information

Authorized Official

Authorized Official Last Name:
LEASE
Authorized Official First Name:
RITA
Authorized Official Middle Name:
Authorized Official Title or Position:
NURSE PRACTIONER
Authorized Official Telephone Number:
608-572-3494

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  4062-33 , 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: 849190006 . This is a "MEDICARE PTAN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1215243852 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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