Provider Demographics
NPI:1184220659
Name:ROCK RIVER COMMUNITY CLINIC INC
Entity Type:Organization
Organization Name:ROCK RIVER COMMUNITY CLINIC INC
Other - Org Name:ROCK RIVER COMMUNITY CLINIC INC
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CORI
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:OLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-563-4372
Mailing Address - Street 1:1461 W MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:WHITEWATER
Mailing Address - State:WI
Mailing Address - Zip Code:53190-1568
Mailing Address - Country:US
Mailing Address - Phone:262-472-6839
Mailing Address - Fax:262-472-6802
Practice Address - Street 1:1461 W MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:WHITEWATER
Practice Address - State:WI
Practice Address - Zip Code:53190-1568
Practice Address - Country:US
Practice Address - Phone:262-472-6839
Practice Address - Fax:262-472-6802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-09
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health