Basic Information
| Provider Information | |||||||||
| NPI: | 1649571787 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARSH COUNTRY HEALTH ALLIANCE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MCHA NORTH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 199 HOME ROAD | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530391402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203863400 | ||||||||
| FaxNumber: | 9203863800 | ||||||||
| Practice Location | |||||||||
| Address1: | 199 HOME RD | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530391402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203863400 | ||||||||
| FaxNumber: | 9203863800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2010 | ||||||||
| LastUpdateDate: | 12/13/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOOPER | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9203863409 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | NHA RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | WI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 20145400 | 05 | WI | MEDICAID |