Provider Demographics
NPI:1376650499
Name:FOREST COUNTY POTAWATOMI HEALTH & WELLNESS CENTER
Entity Type:Organization
Organization Name:FOREST COUNTY POTAWATOMI HEALTH & WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRIBAL CHAIRMAN
Authorized Official - Prefix:MR
Authorized Official - First Name:NED
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-478-4824
Mailing Address - Street 1:PO BOX 396
Mailing Address - Street 2:8201 MISH KO SWEN DRIVE
Mailing Address - City:CRANDON
Mailing Address - State:WI
Mailing Address - Zip Code:54520-0396
Mailing Address - Country:US
Mailing Address - Phone:715-478-4300
Mailing Address - Fax:715-478-4490
Practice Address - Street 1:8201 MISH KO SWEN DR
Practice Address - Street 2:
Practice Address - City:CRANDON
Practice Address - State:WI
Practice Address - Zip Code:54520-8631
Practice Address - Country:US
Practice Address - Phone:715-478-4300
Practice Address - Fax:715-478-4490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42182600Medicaid