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NPI Code Detail

MEDICARE: PINE VALLEY INTEGRATED SERVICES LLC

MEDICARE: PINE VALLEY INTEGRATED SERVICES LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker
2251S00000XCommunity/Behavioral Health Agency

General Provider Information

NPI Number : 1013375104
Entity Type Code : Organization
Provider Name (Legal Business Name) : PINE VALLEY INTEGRATED SERVICES LLC
Provider Business Mailing Address
First Line : PO BOX 359
Second Line :
City : MAUSTON
State : WI
Zip : 53948-0359
Country : US
Telephone Number : 608-847-7575
Fax Number : 608-847-3096
Provider Business Practice Location Address
First Line : 124 GRAYSIDE AVE
Second Line :
City : MAUSTON
State : WI
Zip : 53948-1913
Country : US
Telephone Number : 608-847-7575
Fax Number : 608-847-3096
Authorized Official
Title or Position : CEO / OWNER MEMBER LLC
Name : JESSICA SCHULZ
Credential :
Telephone Number : 608-847-7575
Provider Enumeration Date : 02/03/2016
Last Update Date : 08/28/2023

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