Provider Demographics
NPI:1346821642
Name:WAKODA TRAILS LLC
Entity Type:Organization
Organization Name:WAKODA TRAILS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR/INSTRUCTOR
Authorized Official - Prefix:
Authorized Official - First Name:CORINNE
Authorized Official - Middle Name:L
Authorized Official - Last Name:SCHARDT
Authorized Official - Suffix:
Authorized Official - Credentials:CTRI
Authorized Official - Phone:920-590-1397
Mailing Address - Street 1:7425 RED BANKS RD
Mailing Address - Street 2:
Mailing Address - City:GILLETT
Mailing Address - State:WI
Mailing Address - Zip Code:54124-9749
Mailing Address - Country:US
Mailing Address - Phone:920-590-1397
Mailing Address - Fax:
Practice Address - Street 1:7425 RED BANKS RD
Practice Address - Street 2:
Practice Address - City:GILLETT
Practice Address - State:WI
Practice Address - Zip Code:54124-9749
Practice Address - Country:US
Practice Address - Phone:920-590-1397
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-19
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health