Provider Demographics
NPI:1154501856
Name:MILE BLUFF CLINIC, LLP
Entity Type:Organization
Organization Name:MILE BLUFF CLINIC, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:FRONK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-847-5000
Mailing Address - Street 1:1040 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:MAUSTON
Mailing Address - State:WV
Mailing Address - Zip Code:53948
Mailing Address - Country:US
Mailing Address - Phone:608-847-5000
Mailing Address - Fax:
Practice Address - Street 1:1104 21ST ST
Practice Address - Street 2:
Practice Address - City:REEDSBURG
Practice Address - State:WI
Practice Address - Zip Code:53959-1156
Practice Address - Country:US
Practice Address - Phone:608-524-6487
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41679000Medicaid
WI41679000Medicaid