Healthcare Provider Details

I. General information

NPI: 1689891046
Provider Name (Legal Business Name): AGNESIAN HEALTHCARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 11/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 MEMORIAL DR
BERLIN WI
54923-1243
US

IV. Provider business mailing address

420 E DIVISION ST
FOND DU LAC WI
54935-4560
US

V. Phone/Fax

Practice location:
  • Phone: 920-926-4100
  • Fax:
Mailing address:
  • Phone: 920-926-8340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: STEVEN N LITTLE
Title or Position: SVP & CFO
Credential:
Phone: 920-926-5402