Provider Demographics
NPI:1417156464
Name:WESTERN RACINE COUNTY HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:WESTERN RACINE COUNTY HEALTH DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/HEALTH OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZMANIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-763-4931
Mailing Address - Street 1:156 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-1940
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:156 E STATE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1940
Practice Address - Country:US
Practice Address - Phone:262-763-4930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41871000Medicaid
WI97056Medicare PIN