Healthcare Provider Details

I. General information

NPI: 1477005544
Provider Name (Legal Business Name): PRAIRIE RIDGE HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W MAIN ST
MARSHALL WI
53559-9799
US

IV. Provider business mailing address

PO BOX 418
MARSHALL WI
53559-0418
US

V. Phone/Fax

Practice location:
  • Phone: 920-623-2200
  • Fax: 920-623-1441
Mailing address:
  • Phone: 608-655-8181
  • Fax: 608-655-8224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number2985
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number21498-20
License Number StateWI

VIII. Authorized Official

Name: MR. JOHN RUSSELL
Title or Position: PRESIDENT & CEO
Credential:
Phone: 920-623-1368