1982812426 NPI number — CLARK COUNTY HEALTH CARE CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982812426 NPI number — CLARK COUNTY HEALTH CARE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLARK COUNTY HEALTH CARE CENTER
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:
1982812426
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
N13874 COUNTY ROAD O
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WITHEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54498-9045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
W4266 STATE ROAD 29
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OWEN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54460-8932
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-229-2172
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SCHIMDT
Authorized Official First Name:
JANE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
715-229-2172

Provider Taxonomy Codes

  • Taxonomy code: 224Z00000X , with the licence number:  29-027 , 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: 40608400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 29-027 . This is a "O.T. LIC." identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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