Basic Information
| Provider Information | |||||||||
| NPI: | 1801036447 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOREST COUNTY POTAWATOMI HEALTH & WELLNESS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 396 | ||||||||
| Address2: | |||||||||
| City: | CRANDON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545200396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154784300 | ||||||||
| FaxNumber: | 7154784490 | ||||||||
| Practice Location | |||||||||
| Address1: | 8201 MISHKOSWEN DR | ||||||||
| Address2: | |||||||||
| City: | CRANDON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545200396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154784300 | ||||||||
| FaxNumber: | 7154784490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2009 | ||||||||
| LastUpdateDate: | 12/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | DANIELS | ||||||||
| AuthorizedOfficialFirstName: | NED | ||||||||
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| AuthorizedOfficialTitleorPosition: | TRIBAL CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 7154784824 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 41752300 | 05 | WI | MEDICAID |