|
| |
|
230 W Park Street Wautoma WI 54982-9031 | |
| (920) 787-6550 | |
| (920) 787-0421 |
| Full Name | |
|---|---|
| Speciality | Community/behavioral Health |
| Location | 230 W Park Street, Wautoma, Wisconsin |
| Authorized Official Name and Position | Victoria L Ida (ACCOUNT CLERK) |
| Authorized Official Contact | 9207876618 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 1230 Wautoma WI 54982-1230 Ph: (920) 787-6600 | 230 W Park Street Wautoma WI 54982-9031 Ph: (920) 787-6550 |
| NPI Number | 1598938557 |
|---|---|
| Provider Enumeration Date | 04/10/2008 |
| Last Update Date | 12/29/2014 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1598938557 | NPI | - | NPPES |
| 32976970 | Medicaid | WI |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | 1980 (Wisconsin) | Primary |