Healthcare Provider Details

I. General information

NPI: 1649302399
Provider Name (Legal Business Name): LACROSSE CBOC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 STATE RD
LA CROSSE WI
54601-6157
US

IV. Provider business mailing address

2600 STATE RD
LA CROSSE WI
54601-6157
US

V. Phone/Fax

Practice location:
  • Phone: 608-784-3886
  • Fax:
Mailing address:
  • Phone: 608-784-3886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BARBARA MAYERICK
Title or Position: DIRECTOR, BUSINESS DEVELOPMENT
Credential:
Phone: 202-254-0339