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General NPI Number Information
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NPI Number | 1285922971
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Entity Type | Organization
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Legal Business Name | BLANDINE HOUSE INC
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Dates
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Enumeration Date | 07/14/2011
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Last Update Date | 07/14/2011
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Provider Practice Location Address
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Address Line | 25 N PARK AVE
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City | FOND DU LAC
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State | WI
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Zip | 54935-3501
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Country | US
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Telephone | 920-922-9487
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Fax | 920-922-9184
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Provider Business Mailing Address
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Address Line | 25 N PARK AVE
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City | FOND DU LAC
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State | WI
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Zip | 54935-3501
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Country | US
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Telephone | 920-922-9487
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Fax | 920-922-9184
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. JAMES COLWIN
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Credential |
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Telephone | 920-922-9487
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 1068-800
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License Number State | WI
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