Provider Demographics
NPI:1376549824
Name:VERNON MEMORIAL HEALTHCARE, INC.
Entity Type:Organization
Organization Name:VERNON MEMORIAL HEALTHCARE, INC.
Other - Org Name:KICKAPOO VALLEY MEDICAL CLINIC - VMH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-637-4796
Mailing Address - Street 1:507 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VIROQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54665-2059
Mailing Address - Country:US
Mailing Address - Phone:608-624-5203
Mailing Address - Fax:608-638-5039
Practice Address - Street 1:102 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:SOLDIERS GROVE
Practice Address - State:WI
Practice Address - Zip Code:54655-1400
Practice Address - Country:US
Practice Address - Phone:608-624-5203
Practice Address - Fax:608-624-5572
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VERNON MEMORIAL HEALTHCARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-21
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
523999Medicare ID - Type Unspecified