Basic Information
Provider Information | |||||||||
NPI: | 1487960167 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAMILY & CHILDREN'S CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FAMILY & CHILDREN'S CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1707 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | LA CROSSE | ||||||||
State: | WI | ||||||||
PostalCode: | 546014200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6087850001 | ||||||||
FaxNumber: | 6087850002 | ||||||||
Practice Location | |||||||||
Address1: | 1707 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | LA CROSSE | ||||||||
State: | WI | ||||||||
PostalCode: | 546014200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6087850001 | ||||||||
FaxNumber: | 6087850002 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/19/2010 | ||||||||
LastUpdateDate: | 01/13/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOEHM | ||||||||
AuthorizedOfficialFirstName: | MIKE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
AuthorizedOfficialTelephone: | 6087850001 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | FAMILY & CHILDREN'S CENTER, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 385HR2055X |   |   | Y |   | Respite Care Facility | Respite Care | Respite Care, Mental Illness, Child |
No ID Information.