Basic Information
Provider Information | |||||||||
NPI: | 1922263656 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HO CHUNK NATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HO-CHUNK COMMUNITY HEALTH CARE NURSING PROGRAM | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | N6520 LUMBERJACK GUY RD | ||||||||
Address2: |   | ||||||||
City: | BLACK RIVER FALLS | ||||||||
State: | WI | ||||||||
PostalCode: | 546155405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7152849851 | ||||||||
FaxNumber: | 7152845051 | ||||||||
Practice Location | |||||||||
Address1: | N6520 LUMBERJACK GUY RD | ||||||||
Address2: |   | ||||||||
City: | BLACK RIVER FALLS | ||||||||
State: | WI | ||||||||
PostalCode: | 546155405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7152849851 | ||||||||
FaxNumber: | 7152845051 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/22/2008 | ||||||||
LastUpdateDate: | 03/23/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LUND | ||||||||
AuthorizedOfficialFirstName: | LIZ | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | PROVIDER NETWORK MANAGER | ||||||||
AuthorizedOfficialTelephone: | 7152849851 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | HO CHUNK NATION | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 52D2018007 | 01 | WI | CLIA | OTHER | 44015100 | 05 | WI |   | MEDICAID |