Provider Demographics
NPI:1225150170
Name:HUMAN SERVICES BOARD SERVING NORTH CENTRAL HEALTH CARE FACILITY
Entity Type:Organization
Organization Name:HUMAN SERVICES BOARD SERVING NORTH CENTRAL HEALTH CARE FACILITY
Other - Org Name:NORTH CENTRAL HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-848-4600
Mailing Address - Street 1:1100 LAKE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-6785
Mailing Address - Country:US
Mailing Address - Phone:715-848-4600
Mailing Address - Fax:715-845-5398
Practice Address - Street 1:1225 LANGLADE RD
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2762
Practice Address - Country:US
Practice Address - Phone:715-627-6694
Practice Address - Fax:715-627-6645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2298261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43426700Medicaid