1649397654 NPI number — FAMILY SERVICES OF NORTHEAST WISCONSIN, INC.

Table of content: (NPI 1649397654)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649397654 NPI number — FAMILY SERVICES OF NORTHEAST WISCONSIN, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY SERVICES OF NORTHEAST WISCONSIN, INC.
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:
FAMILY SERVICES - FOX VALLEY DAY TREATMENT
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:
1649397654
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 CROOKS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREEN BAY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54301-4527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-436-6800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 W ROGERS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
APPLETON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54914-5007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-954-6804
Provider Business Practice Location Address Fax Number:
920-954-6806
Provider Enumeration Date:
03/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT-CEO
Authorized Official Telephone Number:
920-436-6800

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , with the licence number:  2561 , 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: 43008200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com