=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497148274
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CUMBERLAND HC MEDICAL CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2015
-----------------------------------------------------
Last Update Date | 03/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1705 16TH AVE
-----------------------------------------------------
City | CUMBERLAND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54829-8601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-822-7500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1705 16TH AVE
-----------------------------------------------------
City | CUMBERLAND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54829-8601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-822-7500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | EMILY DILLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 715-822-7252
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------