Provider Demographics
NPI:1003819491
Name:COUNTY OF PORTAGE
Entity Type:Organization
Organization Name:COUNTY OF PORTAGE
Other - Org Name:PORTAGE COUNTY HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-346-1497
Mailing Address - Street 1:825 WHITING AVE
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-5246
Mailing Address - Country:US
Mailing Address - Phone:715-346-1375
Mailing Address - Fax:715-346-1628
Practice Address - Street 1:825 WHITING AVE
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-5246
Practice Address - Country:US
Practice Address - Phone:715-346-1375
Practice Address - Fax:715-346-1628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2394314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20134800Medicaid
525611Medicare UPIN