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General NPI Number Information
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NPI Number | 1023527769
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Entity Type | Organization
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Legal Business Name | RED ROAD HOUSE
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Dates
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Enumeration Date | 09/26/2017
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Last Update Date | 06/11/2019
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Provider Practice Location Address
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Address Line | 152 S LOCUST ST
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City | JANESVILLE
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State | WI
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Zip | 53548-3767
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Country | US
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Telephone | 608-756-9252
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Fax |
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Provider Business Mailing Address
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Address Line | 152 S LOCUST ST
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City | JANESVILLE
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State | WI
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Zip | 53548-3767
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Country | US
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Telephone | 608-756-2592
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Fax | 608-756-2592
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Authorized Official
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Title or Position | FOUNDER/DIRECTOR
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Name | MISS WILLIAM GRAHN
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Credential |
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Telephone | 608-756-2592
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 405300000X
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Taxonomy Name | Prevention Professional
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License Number |
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License Number State | WI
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