Provider Demographics
NPI:1518339480
Name:GRANT REGIONAL HEALTH CENTER, INC
Entity Type:Organization
Organization Name:GRANT REGIONAL HEALTH CENTER, INC
Other - Org Name:GRANT REGIONAL COMMUNITY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BANDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-723-3202
Mailing Address - Street 1:507 S MONROE ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:WI
Mailing Address - Zip Code:53813-2054
Mailing Address - Country:US
Mailing Address - Phone:608-723-2131
Mailing Address - Fax:608-723-4464
Practice Address - Street 1:507 S MONROE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:WI
Practice Address - Zip Code:53813-2054
Practice Address - Country:US
Practice Address - Phone:608-723-2131
Practice Address - Fax:608-723-4464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-30
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207Q00000X, 207V00000X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty