Provider Demographics
NPI:1568196764
Name:BLACK RIVER MEMORIAL HOSPITAL INC
Entity Type:Organization
Organization Name:BLACK RIVER MEMORIAL HOSPITAL INC
Other - Org Name:BLACK RIVER HEALTHCARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:SELVICK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, MBA, FACHE
Authorized Official - Phone:715-284-5361
Mailing Address - Street 1:711 W ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-5052
Mailing Address - Country:US
Mailing Address - Phone:715-284-5361
Mailing Address - Fax:
Practice Address - Street 1:711 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-5052
Practice Address - Country:US
Practice Address - Phone:715-284-5361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-13
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health