Basic Information
| Provider Information | |||||||||
| NPI: | 1639553100 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HO-CHUNK HEALTH CARE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | N6520 LUMBERJACK GUY RD | ||||||||
| Address2: | |||||||||
| City: | BLACK RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152849851 | ||||||||
| FaxNumber: | 7152843434 | ||||||||
| Practice Location | |||||||||
| Address1: | N6520 LUMBERJACK GUY RD | ||||||||
| Address2: | |||||||||
| City: | BLACK RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152849851 | ||||||||
| FaxNumber: | 7152843434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2015 | ||||||||
| LastUpdateDate: | 07/15/2015 | ||||||||
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| AuthorizedOfficialLastName: | DOZER | ||||||||
| AuthorizedOfficialFirstName: | RACHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | BEHAVIORAL HEALTH CLINICIAN 1 | ||||||||
| AuthorizedOfficialTelephone: | 7152996949 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | APSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305R00000X | 1407911795 | WI | Y | Managed Care Organizations | Preferred Provider Organization |
No ID Information.