Healthcare Provider Details

I. General information

NPI: 1588110969
Provider Name (Legal Business Name): PREVEA CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 01/12/2022
Certification Date: 01/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2449 COUNTY HIGHWAY I
CHIPPEWA FALLS WI
54729-4410
US

IV. Provider business mailing address

PO BOX 13008
GREEN BAY WI
54307-3008
US

V. Phone/Fax

Practice location:
  • Phone: 920-496-4700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ASHOK RAI
Title or Position: PRESIDENT AND CEO
Credential: MD
Phone: 920-496-4700