Provider Demographics
NPI: | 1518432251 |
---|---|
Name: | INDIANHEAD MEDICAL CENTER SHELL LAKE, INC. |
Entity Type: | Organization |
Organization Name: | INDIANHEAD MEDICAL CENTER SHELL LAKE, INC. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | DIRECTOR OF NURSING |
Authorized Official - Prefix: | |
Authorized Official - First Name: | DORIS |
Authorized Official - Middle Name: | JEAN |
Authorized Official - Last Name: | LAURSEN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 715-468-7833 |
Mailing Address - Street 1: | PO BOX 58 |
Mailing Address - Street 2: | |
Mailing Address - City: | SIREN |
Mailing Address - State: | WI |
Mailing Address - Zip Code: | 54872-0058 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 715-349-2910 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 7728 W MAIN ST |
Practice Address - Street 2: | |
Practice Address - City: | SIREN |
Practice Address - State: | WI |
Practice Address - Zip Code: | 54872-8041 |
Practice Address - Country: | US |
Practice Address - Phone: | 153-492-9107 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2018-10-09 |
Last Update Date: | 2018-10-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QR1300X | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WI | K100372638 | Medicaid |