Basic Information
| Provider Information | |||||||||
| NPI: | 1043720352 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DODGE COUNTY MEDICAL FACILITIES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CLEARVIEW BEHAVIORAL HEALTH 3 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 198 COUNTY DF | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530399515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203863400 | ||||||||
| FaxNumber: | 9203864168 | ||||||||
| Practice Location | |||||||||
| Address1: | 198 COUNTY DF | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530399515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203863400 | ||||||||
| FaxNumber: | 9203864168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2017 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOOPER | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
| AuthorizedOfficialMiddleName: | ELIZABETH | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9203863400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 5049 | WI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 5049 | 01 | WI | 314000000X | OTHER |