Healthcare Provider Details

I. General information

NPI: 1780636480
Provider Name (Legal Business Name): GUNDERSEN CLINIC, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 03/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35791 OSSEO RD
INDEPENDENCE WI
54747-9096
US

IV. Provider business mailing address

1836 SOUTH AVE
LA CROSSE WI
54601-5429
US

V. Phone/Fax

Practice location:
  • Phone: 608-782-7300
  • Fax:
Mailing address:
  • Phone: 608-782-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KARI B ADANK
Title or Position: CCO
Credential:
Phone: 608-775-8025