Basic Information
| Provider Information | |||||||||
| NPI: | 1215194907 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKEVIEW MEDICAL CENTER, INC. OF RICE LAKE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RICE LAKE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548681238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152341515 | ||||||||
| FaxNumber: | 7152344465 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RICE LAKE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548681238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152341515 | ||||||||
| FaxNumber: | 7152344465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2008 | ||||||||
| LastUpdateDate: | 11/06/2008 | ||||||||
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| AuthorizedOfficialLastName: | KLEIN | ||||||||
| AuthorizedOfficialFirstName: | JACQUELINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7152366129 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 1562800 | WI | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | 1562800 | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 41214500 | 05 | WI | MEDICAID |