Healthcare Provider Details

I. General information

NPI: 1235266065
Provider Name (Legal Business Name): NORTHWEST PASSAGE LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 03/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 UNITED WAY DRIVE
FREDERIC WI
54837-8938
US

IV. Provider business mailing address

203 UNITED WAY DRIVE
FREDERIC WI
54837-8938
US

V. Phone/Fax

Practice location:
  • Phone: 715-327-4402
  • Fax: 715-327-4470
Mailing address:
  • Phone: 715-327-4322
  • Fax: 715-327-8509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number560014
License Number StateWI

VIII. Authorized Official

Name: JACKIE J MAURER
Title or Position: BUSINESS OFFICE SUPERVISOR
Credential:
Phone: 715-327-4322