Basic Information
| Provider Information | |||||||||
| NPI: | 1063658557 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY & CHILDREN'S CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HIAWATHA HALL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1707 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LA CROSSE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546014200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087850001 | ||||||||
| FaxNumber: | 6087850002 | ||||||||
| Practice Location | |||||||||
| Address1: | 428 W BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | WINONA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559875216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5074547711 | ||||||||
| FaxNumber: | 5074520325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2009 | ||||||||
| LastUpdateDate: | 01/11/2012 | ||||||||
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| AuthorizedOfficialLastName: | BOEHM | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO, PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6087850001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAMILY & CHILDREN'S CENTER, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.