Basic Information
| Provider Information | |||||||||
| NPI: | 1144325267 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROWN COUNTY HEALTH CARE CENTER BAYVIEW DEVELPMENTAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 SAINT ANTHONY DR | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543115859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203914700 | ||||||||
| FaxNumber: | 9203914870 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 SAINT ANTHONY DR | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543115859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203914700 | ||||||||
| FaxNumber: | 9203914870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PIVONKA | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INPATIENT SERVICES DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9203914700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | RN, MS, APNP, NHA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320600000X | 2986 | WI | Y | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 21050800 | 05 | WI | MEDICAID |