Provider Demographics
NPI:1114963261
Name:AGNESIAN HEALTHCARE
Entity Type:Organization
Organization Name:AGNESIAN HEALTHCARE
Other - Org Name:FOND DU LAC REGIONAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP & CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-926-5402
Mailing Address - Street 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-8340
Mailing Address - Fax:
Practice Address - Street 1:100 EVERGREEN RD
Practice Address - Street 2:
Practice Address - City:MOUNT CALVARY
Practice Address - State:WI
Practice Address - Zip Code:53057-9726
Practice Address - Country:US
Practice Address - Phone:920-753-2311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0302620013Medicare NSC