Provider Demographics
NPI:1063837557
Name:THEDACARE MEDICAL CENTER - WAUPACA, INC.
Entity Type:Organization
Organization Name:THEDACARE MEDICAL CENTER - WAUPACA, INC.
Other - Org Name:RIVERSIDE MEDICAL CENTER, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-454-4013
Mailing Address - Street 1:6501 CITY WEST PKWY
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3248
Mailing Address - Country:US
Mailing Address - Phone:952-653-2525
Mailing Address - Fax:
Practice Address - Street 1:6501 CITY WEST PKWY
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3248
Practice Address - Country:US
Practice Address - Phone:952-653-2525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-20
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site