Basic Information
| Provider Information | |||||||||
| NPI: | 1457532616 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY & CHILDREN'S CENTER, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EMHS-VERNON COUNTY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1707 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LA CROSSE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546014200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087850001 | ||||||||
| FaxNumber: | 6087850002 | ||||||||
| Practice Location | |||||||||
| Address1: | 1321 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | VIROQUA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546651156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086377052 | ||||||||
| FaxNumber: | 6086378500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2007 | ||||||||
| LastUpdateDate: | 01/11/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOEHM | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO, PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6087850001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAMILY & CHILDREN'S CENTER, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 32980600 | 05 | WI | MEDICAID |