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General NPI Number Information
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NPI Number | 1548387657
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Entity Type | Organization
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Legal Business Name | NORTHWEST JOURNEY - BLACK RIVER FALLS
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Dates
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Enumeration Date | 03/23/2007
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Last Update Date | 09/23/2010
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Provider Practice Location Address
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Address Line | N6643 COUNTY ROAD A
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City | BLACK RIVER FALLS
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State | WI
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Zip | 54615-5852
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Country | US
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Telephone | 715-284-1100
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Fax | 715-284-1145
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Provider Business Mailing Address
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Address Line | N6643 COUNTY ROAD A
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City | BLACK RIVER FALLS
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State | WI
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Zip | 54615-5852
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Country | US
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Telephone | 715-284-1100
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Fax | 715-284-1145
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Authorized Official
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Title or Position | CFO
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Name | MR. NICK KALAMBOKIDIS
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Credential |
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Telephone | 715-327-4402
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number | 2655
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License Number State | WI
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