Provider Demographics
NPI:1285864389
Name:PRIMARY CONNECTION HEALTHCARE, INC.
Entity Type:Organization
Organization Name:PRIMARY CONNECTION HEALTHCARE, INC.
Other - Org Name:BRIDGE COMMUNITY HEALTH CLINIC MENTAL HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCUDIERE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-848-4884
Mailing Address - Street 1:1810 2ND ST
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-3492
Mailing Address - Country:US
Mailing Address - Phone:715-848-4884
Mailing Address - Fax:715-845-5385
Practice Address - Street 1:1810 2ND ST
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-3492
Practice Address - Country:US
Practice Address - Phone:715-848-4884
Practice Address - Fax:715-845-5385
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIMARY CONNECTION HEALTHCARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-23
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIPENDING251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIPENDINGMedicaid
WIPENDINGOtherOUTPATIENT MENTAL HEALTH CLINIC CERTIFICATION NUMBER