Healthcare Provider Details

I. General information

NPI: 1639336894
Provider Name (Legal Business Name): JOHN CHARLES ROURKE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2008
Last Update Date: 05/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11000 BLISS ST.
BLUE MOUNDS WI
53517-0153
US

IV. Provider business mailing address

PO BOX 153
BLUE MOUNDS WI
53517-0153
US

V. Phone/Fax

Practice location:
  • Phone: 608-437-6167
  • Fax:
Mailing address:
  • Phone: 608-437-6167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number121292-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: