Basic Information
| Provider Information | |||||||||
| NPI: | 1285741306 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOREST COUNTY POTAWATOMI COMMUNITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | POTAWATOMI HEALTH & WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 396 | ||||||||
| Address2: | |||||||||
| City: | CRANDON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545200396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154784300 | ||||||||
| FaxNumber: | 7154784490 | ||||||||
| Practice Location | |||||||||
| Address1: | 8201 MISH KO SWEN DRIVE | ||||||||
| Address2: | |||||||||
| City: | CRANDON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545208631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154784300 | ||||||||
| FaxNumber: | 7154784300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DANIELS | ||||||||
| AuthorizedOfficialFirstName: | NED | ||||||||
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| AuthorizedOfficialTitleorPosition: | TRIBAL CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 7154784824 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 132700000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietary Manager | 133N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Nutritionist | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 261QC1500X | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QD0000X | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QH0700X | N | Ambulatory Health Care Facilities | Clinic/Center | Hearing and Speech | 261QP1100X | N | Ambulatory Health Care Facilities | Clinic/Center | Podiatric | 261QR0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 261QR0206X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography | 291U00000X | N | Laboratories | Clinical Medical Laboratory | 332800000X | N | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332H00000X | N | Suppliers | Eyewear Supplier (Equipment, not the service) | 332S00000X | N | Suppliers | Hearing Aid Equipment | 261QF0400X | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 391235059016 | 01 | WI | BLUE CROSS BLUE SHIELD | OTHER | 41752300 | 01 | WI | DURABLE MEDICAL EQUIPMENT | OTHER | 42182600 | 01 | WI | AODA CLINIC | OTHER | 32956600 | 05 | WI | MEDICAID | 42182600 | 01 | WI | MENTAL HEALTH | OTHER | DA0385 | 01 | WI | RAILROAD MEDICARE | OTHER | 42182600 | 05 | WI | MEDICAID | 44006100 | 01 | WI | PRENATAL CARE | OTHER | 44006100 | 05 | WI | MEDICAID | 41752300 | 05 | WI | MEDICAID |