Provider Demographics
NPI:1073067013
Name:INTERRA HEALTH INC.
Entity Type:Organization
Organization Name:INTERRA HEALTH INC.
Other - Org Name:BREAKBUSH CENTER FOR HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:IMPLEMENTATION & TRAINING COORDINAT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:D
Authorized Official - Last Name:RUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-375-1600
Mailing Address - Street 1:8919 W HEATHER AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53224-2417
Mailing Address - Country:US
Mailing Address - Phone:414-375-1600
Mailing Address - Fax:414-375-1639
Practice Address - Street 1:N4993 6TH DR
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:WI
Practice Address - Zip Code:53964-8200
Practice Address - Country:US
Practice Address - Phone:608-296-2121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-08
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1417905035261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care