1154707974 NPI number — WESTERN REGION RECOVERY & WELLNESS CONSORTIA

Table of content: (NPI 1154707974)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154707974 NPI number — WESTERN REGION RECOVERY & WELLNESS CONSORTIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTERN REGION RECOVERY & WELLNESS CONSORTIA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
POLK COUNTY DEPARTMENT OF HUMAN SERVICES
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154707974
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
711 N BRIDGE ST RM 305
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHIPPEWA FALLS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54729-1845
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-726-7787
Provider Business Mailing Address Fax Number:
715-726-7736

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 POLK COUNTY PLZ STE 50
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALSAM LAKE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54810-9097
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-485-8400
Provider Business Practice Location Address Fax Number:
715-485-8490
Provider Enumeration Date:
08/04/2015

Additional Information

Authorized Official

Authorized Official Last Name:
ZACHAU
Authorized Official First Name:
MARY
Authorized Official Middle Name:
K
Authorized Official Title or Position:
FISCAL MANAGER
Authorized Official Telephone Number:
715-726-7787

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  3065 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3065 . This is a "STATE OF WISCONSIN CERTIFICATION" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com