Basic Information
Provider Information | |||||||||
NPI: | 1316002694 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HO CHUNK NATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | S2845 WHITE EAGLE RD | ||||||||
Address2: |   | ||||||||
City: | BARABOO | ||||||||
State: | WI | ||||||||
PostalCode: | 539139064 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083551240 | ||||||||
FaxNumber: | 6083567122 | ||||||||
Practice Location | |||||||||
Address1: | S2845 WHITE EAGLE RD | ||||||||
Address2: |   | ||||||||
City: | BARABOO | ||||||||
State: | WI | ||||||||
PostalCode: | 539139064 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083551240 | ||||||||
FaxNumber: | 6083567122 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/27/2006 | ||||||||
LastUpdateDate: | 03/26/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LUND | ||||||||
AuthorizedOfficialFirstName: | LIZ | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | PROVIDER NETWORK MANAGER | ||||||||
AuthorizedOfficialTelephone: | 7152849851 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center |   | 261QM0801X | 1413 | WI | N |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 32957200 | 05 | WI |   | MEDICAID |