Provider Demographics
NPI:1215402334
Name:AGNESIAN HEALTHCARE INC
Entity Type:Organization
Organization Name:AGNESIAN HEALTHCARE INC
Other - Org Name:SSM HEALTH FOND DU LAC REGIONAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:VERGOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-926-4979
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:920-926-8332
Mailing Address - Fax:
Practice Address - Street 1:130 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3116
Practice Address - Country:US
Practice Address - Phone:920-887-3102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-04
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies