Healthcare Provider Details

I. General information

NPI: 1073905865
Provider Name (Legal Business Name): OAKLEAF CLINICS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2015
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 OAK RIDGE DR
EAU CLAIRE WI
54701-6133
US

IV. Provider business mailing address

1110 OAK RIDGE DR
EAU CLAIRE WI
54701-6133
US

V. Phone/Fax

Practice location:
  • Phone: 715-834-9998
  • Fax: 715-834-9833
Mailing address:
  • Phone: 715-834-9998
  • Fax: 715-834-9833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. CHRIS R LONGBELLA
Title or Position: DIRECTOR
Credential: MD
Phone: 715-836-9242