=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891442174
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREAT RIVER ORTHODONTIC SPECIALISTS, SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2022
-----------------------------------------------------
Last Update Date | 03/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2215 VINE ST STE B
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54016-5862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-808-8379
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3902 OAKWOOD HILLS PKWY
-----------------------------------------------------
City | EAU CLAIRE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54701-7780
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PATIENT ACCOUNTS MGR
-----------------------------------------------------
Name | LORI AMIDON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 715-598-7473
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------