Provider Demographics
NPI:1407002546
Name:COMMUNITY CARE OF CENTRAL WISCONSIN
Entity Type:Organization
Organization Name:COMMUNITY CARE OF CENTRAL WISCONSIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LUCY
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:RUNNELLS
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:715-204-1810
Mailing Address - Street 1:3349 CHURCH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-5314
Mailing Address - Country:US
Mailing Address - Phone:715-345-5968
Mailing Address - Fax:715-345-5725
Practice Address - Street 1:3349 CHURCH ST STE 1
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-5314
Practice Address - Country:US
Practice Address - Phone:715-345-5968
Practice Address - Fax:715-345-5725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-08
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI69005700Medicaid