Healthcare Provider Details

I. General information

NPI: 1417120478
Provider Name (Legal Business Name): COUNTY OF WAUSHARA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2008
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 S TOWNLINE RD
WAUTOMA WI
54982-6900
US

IV. Provider business mailing address

380 S TOWNLINE RD
WAUTOMA WI
54982-6900
US

V. Phone/Fax

Practice location:
  • Phone: 920-787-6550
  • Fax: 920-787-0421
Mailing address:
  • Phone: 920-787-6550
  • Fax: 920-787-0421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number1980
License Number StateWI

VIII. Authorized Official

Name: JEN GONZALES
Title or Position: ACCOUNT CLERK
Credential:
Phone: 920-787-6550