Provider Demographics
NPI:1003951468
Name:FOND DU LAC COUNTY
Entity Type:Organization
Organization Name:FOND DU LAC COUNTY
Other - Org Name:HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:T
Authorized Official - Last Name:HANDRICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-929-3309
Mailing Address - Street 1:459 EAST FIRST STREET
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4505
Mailing Address - Country:US
Mailing Address - Phone:920-929-3500
Mailing Address - Fax:920-929-7046
Practice Address - Street 1:459 EAST FIRST STREET
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4505
Practice Address - Country:US
Practice Address - Phone:920-929-3500
Practice Address - Fax:920-929-7046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2383314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20161200Medicaid