Healthcare Provider Details

I. General information

NPI: 1649547183
Provider Name (Legal Business Name): HEADWATERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2011
Last Update Date: 11/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 E TIMBER DR
RHINELANDER WI
54501-2887
US

IV. Provider business mailing address

PO BOX 618
RHINELANDER WI
54501-0618
US

V. Phone/Fax

Practice location:
  • Phone: 715-369-1337
  • Fax: 715-369-1793
Mailing address:
  • Phone: 715-369-1337
  • Fax: 715-369-1793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code347B00000X
TaxonomyBus
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: MARY HARDTKE
Title or Position: DIRECTOR
Credential:
Phone: 715-369-1337