=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013504075
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKEVIEW MEDICAL CENTER INC OF RICE LAKE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/24/2020
-----------------------------------------------------
Last Update Date | 12/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 806 2ND ST
-----------------------------------------------------
City | CHETEK
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54728-2800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-924-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 N OAK AVE PROVIDER ENROLLMENT SHP FL2
-----------------------------------------------------
City | MARSHFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54449-5703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-389-0660
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO, AO
-----------------------------------------------------
Name | CATHERINE M BUKOWSKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 715-387-9370
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------