Basic Information
Provider Information | |||||||||
NPI: | 1639202005 | ||||||||
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: | 1321 N MAIN ST | ||||||||
Address2: |   | ||||||||
City: | VIROQUA | ||||||||
State: | WI | ||||||||
PostalCode: | 546651156 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6086377052 | ||||||||
FaxNumber: | 6086378500 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/14/2007 | ||||||||
LastUpdateDate: | 01/11/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOEHM | ||||||||
AuthorizedOfficialFirstName: | MIKE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO, PRESIDENT | ||||||||
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 | 261QM0850X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
ID | Type | State | Issuer | Description | 125604 | 01 | MN | UCARE | OTHER | 43425400 | 05 | WI |   | MEDICAID | HPFIN77035 | 01 | MN | HEALTHPARTNERS | OTHER | 163907000 | 01 | WI | MAGELLAN | OTHER |