Basic Information
| Provider Information | |||||||||
| NPI: | 1154501856 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MILE BLUFF CLINIC, LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | MAUSTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 53948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088475000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1104 21ST ST | ||||||||
| Address2: | |||||||||
| City: | REEDSBURG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539591156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6085246487 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2007 | ||||||||
| LastUpdateDate: | 02/26/2008 | ||||||||
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| AuthorizedOfficialLastName: | FRONK | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6088475000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 41679000 | 05 | WI | MEDICAID |