Healthcare Provider Details

I. General information

NPI: 1093868358
Provider Name (Legal Business Name): CHIPPEWA VALLEY TECHNICAL COLLEGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 04/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 W CLAIREMONT AVE HEC 120
EAU CLAIRE WI
54701-6120
US

IV. Provider business mailing address

620 W. CLARIEMONT AVE HEC 120
EAU CLAIRE WI
54701
US

V. Phone/Fax

Practice location:
  • Phone: 715-833-6271
  • Fax: 715-833-6447
Mailing address:
  • Phone: 715-833-6271
  • Fax: 715-833-6447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MS. SHELLY OLSON
Title or Position: CAMPUS ADMINISTRATOR
Credential: MS
Phone: 715-833-6675