Basic Information
| Provider Information | |||||||||
| NPI: | 1033519046 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THEDACARE ACO, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 122 E COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549115794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208305950 | ||||||||
| FaxNumber: | 9208305910 | ||||||||
| Practice Location | |||||||||
| Address1: | 122 E COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549115794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208305950 | ||||||||
| FaxNumber: | 9208305910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2014 | ||||||||
| LastUpdateDate: | 08/27/2014 | ||||||||
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| AuthorizedOfficialLastName: | OLSON | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9208305950 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THEDACARE, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CFO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302F00000X | Y | Managed Care Organizations | Exclusive Provider Organization |
No ID Information.