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General NPI Number Information
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NPI Number | 1477005544
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Entity Type | Organization
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Legal Business Name | PRAIRIE RIDGE HEALTH, INC.
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Dates
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Enumeration Date | 10/25/2016
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Last Update Date | 08/26/2022
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Provider Practice Location Address
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Address Line | 301 W MAIN ST
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City | MARSHALL
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State | WI
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Zip | 53559-9799
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Country | US
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Telephone | 920-623-2200
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Fax | 920-623-1441
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Provider Business Mailing Address
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Address Line | PO BOX 418
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City | MARSHALL
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State | WI
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Zip | 53559-0418
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Country | US
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Telephone | 608-655-8181
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Fax | 608-655-8224
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Authorized Official
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Title or Position | PRESIDENT & CEO
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Name | MR. JOHN RUSSELL
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Credential |
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Telephone | 920-623-1368
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 364SF0001X
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Taxonomy Name | Family Health Clinical Nurse Specialist
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License Number | 2985
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 21498-20
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License Number State | WI
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