MEDICARE: COMMUNITY CLINIC OF DOOR COUNTY, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0050X	Non-Surgical Family Planning Clinic/Center

General Provider Information

NPI Number	:	1598108284
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY CLINIC OF DOOR COUNTY, INC

Provider Business Mailing Address
First Line	:	PO BOX 3
Second Line	:
City	:	STURGEON BAY
State	:	WI
Zip	:	54235-0003
Country	:	US
Telephone Number	:	920-746-8989
Fax Number	:	920-746-8960

Provider Business Practice Location Address
First Line	:	1623 RHODE ISLAND ST
Second Line	:
City	:	STURGEON BAY
State	:	WI
Zip	:	54235-1424
Country	:	US
Telephone Number	:	920-746-8989
Fax Number	:	920-746-8960

Authorized Official
Title or Position	:	BOARD SECRETARY
Name	:	JOSEPHINE GUENZEL
Credential	:
Telephone Number	:	920-746-8989

Provider Enumeration Date	:	04/11/2013
Last Update Date	:	04/11/2013

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