=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538147749
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AGNESIAN HEALTHCARE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2006
-----------------------------------------------------
Last Update Date | 06/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 430 E DIVISION ST
-----------------------------------------------------
City | FOND DU LAC
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54935-4560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-929-2300
-----------------------------------------------------
Fax | 920-926-8885
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 430 E DIVISION ST
-----------------------------------------------------
City | FOND DU LAC
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54935-4560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-929-2300
-----------------------------------------------------
Fax | 920-926-8885
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP-FINANCE, CFO
-----------------------------------------------------
Name | AMY GRINNELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 608-260-3586
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 273Y00000X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Hospital Unit
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------