Healthcare Provider Details

I. General information

NPI: 1619969490
Provider Name (Legal Business Name): VERNON MEMORIAL HEALTHCARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 03/07/2023
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 SUNSET AVE
SOLDIERS GROVE WI
54655-7523
US

IV. Provider business mailing address

407 S MAIN ST STE 104
VIROQUA WI
54665-4004
US

V. Phone/Fax

Practice location:
  • Phone: 608-624-3344
  • Fax: 608-624-3944
Mailing address:
  • Phone: 608-624-3344
  • Fax: 608-624-3944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8490-042
License Number StateWI

VIII. Authorized Official

Name: DAVID HARTBERG
Title or Position: CEO
Credential:
Phone: 608-637-4796