Healthcare Provider Details

I. General information

NPI: 1053468066
Provider Name (Legal Business Name): COUNTY OF GRANT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 04/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 PROFESSIONAL DR
DODGEVILLE WI
53533-1176
US

IV. Provider business mailing address

200 W ALONA LN
LANCASTER WI
53813-2202
US

V. Phone/Fax

Practice location:
  • Phone: 608-935-2776
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JAN SUDMEIER
Title or Position: COMPTROLLER
Credential:
Phone: 608-723-6357