Provider Demographics
NPI: | 1497851265 |
---|---|
Name: | COUNTRY KIDS INC. |
Entity Type: | Organization |
Organization Name: | COUNTRY KIDS INC. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | EXECUTIVE DIRECTOR |
Authorized Official - Prefix: | MS |
Authorized Official - First Name: | LISA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | KAFKA |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | OTR |
Authorized Official - Phone: | 920-339-0700 |
Mailing Address - Street 1: | 1142 ORLANDO DR |
Mailing Address - Street 2: | |
Mailing Address - City: | DE PERE |
Mailing Address - State: | WI |
Mailing Address - Zip Code: | 54115-9484 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 920-339-0700 |
Mailing Address - Fax: | 920-330-0278 |
Practice Address - Street 1: | 1142 ORLANDO DR |
Practice Address - Street 2: | |
Practice Address - City: | DE PERE |
Practice Address - State: | WI |
Practice Address - Zip Code: | 54115-9484 |
Practice Address - Country: | US |
Practice Address - Phone: | 920-339-0700 |
Practice Address - Fax: | 920-330-0278 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-09-16 |
Last Update Date: | 2008-08-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 261QD1600X | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities | |
No | 224Z00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | Group - Multi-Specialty | |
No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
No | 2251P0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | Group - Multi-Specialty |
No | 225200000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | Group - Multi-Specialty | |
No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
No | 225XP0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | Group - Multi-Specialty |
No | 235Z00000X | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | Group - Multi-Specialty | |
No | 261QH0700X | Ambulatory Health Care Facilities | Clinic/Center | Hearing and Speech | |
No | 261QP2000X | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | |
No | 261QX0100X | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WI | 41217200 | Medicaid |