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General NPI Number Information
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NPI Number | 1295783124
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Entity Type | Organization
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Legal Business Name | COUNTY OF TREMPEALEAU
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Dates
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Enumeration Date | 05/04/2006
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Last Update Date | 04/15/2021
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Provider Practice Location Address
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Address Line | 18425 DODGE ST
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City | WHITEHALL
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State | WI
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Zip | 54773-8444
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Country | US
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Telephone | 715-538-4518
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Fax | 715-538-4535
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Provider Business Mailing Address
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Address Line | W20410 STATE ROAD 121
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City | WHITEHALL
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State | WI
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Zip | 54773-9147
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Country | US
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Telephone | 715-538-4312
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Fax | 715-538-2426
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | JERRY DEETZ
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Credential | N.H.A.
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Telephone | 715-538-4312
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number | CBRF474
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License Number State | WI
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