Healthcare Provider Details

I. General information

NPI: 1497812697
Provider Name (Legal Business Name): CLARK COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 09/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W4266 STATE RD. 29
OWEN WI
54460
US

IV. Provider business mailing address

W4266 STATE RD. 29
OWEN WI
54460
US

V. Phone/Fax

Practice location:
  • Phone: 715-229-2172
  • Fax:
Mailing address:
  • Phone: 715-229-2172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2387
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number3014
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: JANE SCHMITZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 715-229-2172