Provider Demographics
NPI:1033115456
Name:SOKAOGON CHIPPEWA COMMUNITY
Entity Type:Organization
Organization Name:SOKAOGON CHIPPEWA COMMUNITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWTON
Authorized Official - Suffix:
Authorized Official - Credentials:CPC, CPB
Authorized Official - Phone:715-622-0293
Mailing Address - Street 1:3144 VANZILE RD
Mailing Address - Street 2:
Mailing Address - City:CRANDON
Mailing Address - State:WI
Mailing Address - Zip Code:54520-8149
Mailing Address - Country:US
Mailing Address - Phone:715-478-5180
Mailing Address - Fax:715-478-5904
Practice Address - Street 1:3144 VANZILE RD
Practice Address - Street 2:
Practice Address - City:CRANDON
Practice Address - State:WI
Practice Address - Zip Code:54520-8149
Practice Address - Country:US
Practice Address - Phone:715-478-5180
Practice Address - Fax:715-478-5904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32957000261QF0400X, 261QF0400X
332800000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32957000Medicaid