Provider Demographics
NPI:1134137557
Name:MAINSTREET CLINIC SC
Entity Type:Organization
Organization Name:MAINSTREET CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KARYL
Authorized Official - Middle Name:L
Authorized Official - Last Name:DEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-682-5601
Mailing Address - Street 1:1001 MAIN ST W
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-1307
Mailing Address - Country:US
Mailing Address - Phone:715-682-5601
Mailing Address - Fax:715-682-6878
Practice Address - Street 1:1001 MAIN ST W
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-1307
Practice Address - Country:US
Practice Address - Phone:715-682-5601
Practice Address - Fax:715-682-6878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32852600Medicaid
WI32852600Medicaid