Basic Information
| Provider Information | |||||||||
| NPI: | 1033115456 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOKAOGON CHIPPEWA COMMUNITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3144 VANZILE RD | ||||||||
| Address2: | |||||||||
| City: | CRANDON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545208149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154785180 | ||||||||
| FaxNumber: | 7154785904 | ||||||||
| Practice Location | |||||||||
| Address1: | 3144 VANZILE RD | ||||||||
| Address2: | |||||||||
| City: | CRANDON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545208149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154785180 | ||||||||
| FaxNumber: | 7154785904 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2005 | ||||||||
| LastUpdateDate: | 09/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | NEWTON | ||||||||
| AuthorizedOfficialFirstName: | LEAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7156220293 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPC, CPB | ||||||||
| NPICertificationDate: | 09/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 32957000 | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 32957000 | 05 | WI | MEDICAID |