Basic Information
| Provider Information | |||||||||
| NPI: | 1770529828 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AGNESIAN HEALTHCARE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FOND DU LAC REGIONAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 E DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549354560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209268340 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 137 CAMBRIA ST | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209265303 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 11/26/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LITTLE | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 9209265402 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.