Basic Information
| Provider Information | |||||||||
| NPI: | 1013069624 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHREACH HEALTHCARE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CRIVITZ MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22487 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543052487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457226 | ||||||||
| FaxNumber: | 9204457229 | ||||||||
| Practice Location | |||||||||
| Address1: | 218 S HWY 141 | ||||||||
| Address2: | |||||||||
| City: | CRIVITZ | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541141677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158547477 | ||||||||
| FaxNumber: | 7158547785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 03/14/2017 | ||||||||
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| AuthorizedOfficialLastName: | HIPKE | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF BUSINESS SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 7157322078 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 52D0394395 | WI | N | Laboratories | Clinical Medical Laboratory | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 52D0394395 | 01 | WI | CLINIC CLIA | OTHER | 4825080007 | 01 | WI | MEDICARE DME | OTHER |