Healthcare Provider Details

I. General information

NPI: 1225160492
Provider Name (Legal Business Name): LA CROSSE COUNTY CMO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 SAINT ANDREW ST STE 100
LA CROSSE WI
54603-2378
US

IV. Provider business mailing address

1407 SAINT ANDREW ST STE 100
LA CROSSE WI
54603-2378
US

V. Phone/Fax

Practice location:
  • Phone: 608-785-6266
  • Fax: 608-785-6315
Mailing address:
  • Phone: 608-785-6266
  • Fax: 608-785-6315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: MR. PATRICK KILLEEN
Title or Position: CMO ADMINISTRATOR
Credential:
Phone: 608-785-6062