Healthcare Provider Details

I. General information

NPI: 1912972613
Provider Name (Legal Business Name): AGNESIAN HEALTHCARE ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 06/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 CAMELOT DR
FOND DU LAC WI
54935-8014
US

IV. Provider business mailing address

307 CAMELOT DR
FOND DU LAC WI
54935-8014
US

V. Phone/Fax

Practice location:
  • Phone: 920-926-5277
  • Fax:
Mailing address:
  • Phone: 920-926-5277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: BONNIE R SCHMITZ
Title or Position: CFO
Credential:
Phone: 920-926-4480