Provider Demographics
NPI:1104207497
Name:PLATTEVILLE FAMILY RESOURCE CENTER
Entity Type:Organization
Organization Name:PLATTEVILLE FAMILY RESOURCE CENTER
Other - Org Name:SW WI REGIONAL ELEM THERAPEUTIC CLASSROOM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:WRUBLE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:608-348-4060
Mailing Address - Street 1:PO BOX 36
Mailing Address - Street 2:
Mailing Address - City:PLATTEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53818-0036
Mailing Address - Country:US
Mailing Address - Phone:608-348-4060
Mailing Address - Fax:608-348-4191
Practice Address - Street 1:155 W LEWIS ST
Practice Address - Street 2:
Practice Address - City:PLATTEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53818-2103
Practice Address - Country:US
Practice Address - Phone:608-642-1563
Practice Address - Fax:608-348-4191
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PLATTEVILLE FAMILY RESOURCE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-12
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39757000Medicaid