| Full Name | |
|---|---|
| Speciality | Community/behavioral Health |
| Location | 230 Park St, Wautoma, Wisconsin |
| Authorized Official Name and Position | Paul F. Theyel (DEPUTY DIRECTOR) |
| Authorized Official Contact | 9207876550 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 1230 230 W. Park Street Wautoma WI 54982-1230 Ph: (920) 787-6550 | 230 Park St Wautoma WI 54982-9031 Ph: (920) 787-6550 |
| NPI Number | 1841463213 |
|---|---|
| Provider Enumeration Date | 04/08/2008 |
| Last Update Date | 04/08/2008 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1841463213 | NPI | - | NPPES |
| 42140600 | Medicaid | WI |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | 1980 (Wisconsin) | Primary |