Provider Demographics
NPI:1396180261
Name:JAMES D WIEDENHOEFT PARTNERSHIP
Entity Type:Organization
Organization Name:JAMES D WIEDENHOEFT PARTNERSHIP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-986-3003
Mailing Address - Street 1:N5367 MAYFLOWER RD
Mailing Address - Street 2:
Mailing Address - City:SHIOCTON
Mailing Address - State:WI
Mailing Address - Zip Code:54170-8934
Mailing Address - Country:US
Mailing Address - Phone:920-986-3003
Mailing Address - Fax:920-986-3004
Practice Address - Street 1:N5367 MAYFLOWER RD
Practice Address - Street 2:
Practice Address - City:SHIOCTON
Practice Address - State:WI
Practice Address - Zip Code:54170-8934
Practice Address - Country:US
Practice Address - Phone:920-986-3003
Practice Address - Fax:920-986-3004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-06
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1447-226261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health