Provider Demographics
NPI:1174848980
Name:LAC COURTE OREILLES PNCC PROGRAM
Entity Type:Organization
Organization Name:LAC COURTE OREILLES PNCC PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:RAE
Authorized Official - Middle Name:E
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-638-5169
Mailing Address - Street 1:13380 W TREPANIA RD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-2186
Mailing Address - Country:US
Mailing Address - Phone:715-638-5100
Mailing Address - Fax:715-634-6107
Practice Address - Street 1:13380 W TREPANIA RD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-2186
Practice Address - Country:US
Practice Address - Phone:715-638-5100
Practice Address - Fax:715-634-6107
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAC COURTE OREILLES COM HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-05
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44007600Medicaid