Healthcare Provider Details

I. General information

NPI: 1629302831
Provider Name (Legal Business Name): COMMUNITY MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2009
Last Update Date: 02/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 S MAIN ST
OCONTO FALLS WI
54154-1241
US

IV. Provider business mailing address

855 S MAIN ST
OCONTO FALLS WI
54154-1241
US

V. Phone/Fax

Practice location:
  • Phone: 920-846-3444
  • Fax: 920-846-0250
Mailing address:
  • Phone: 920-846-3444
  • Fax: 920-846-0250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6699-123
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7421-123
License Number StateWI

VIII. Authorized Official

Name: JIM L VAN DORNICK
Title or Position: CEO
Credential:
Phone: 920-846-3444