Provider Demographics
NPI:1225160492
Name:LA CROSSE COUNTY CMO
Entity Type:Organization
Organization Name:LA CROSSE COUNTY CMO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:KILLEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-785-6062
Mailing Address - Street 1:1407 SAINT ANDREW ST STE 100
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54603-2378
Mailing Address - Country:US
Mailing Address - Phone:608-785-6266
Mailing Address - Fax:608-785-6315
Practice Address - Street 1:1407 SAINT ANDREW ST STE 100
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54603-2378
Practice Address - Country:US
Practice Address - Phone:608-785-6266
Practice Address - Fax:608-785-6315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI69005600Medicaid