Provider Demographics
NPI:1083743272
Name:PREVEA CLINIC, INC.
Entity Type:Organization
Organization Name:PREVEA CLINIC, INC.
Other - Org Name:PREVEA HEALTH - DME OCONTO REGIONAL
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROLSTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-496-4700
Mailing Address - Street 1:620 SMITH AVE
Mailing Address - Street 2:
Mailing Address - City:OCONTO
Mailing Address - State:WI
Mailing Address - Zip Code:54153-1080
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:620 SMITH AVE
Practice Address - Street 2:
Practice Address - City:OCONTO
Practice Address - State:WI
Practice Address - Zip Code:54153-1080
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
4260740003Medicare ID - Type Unspecified