Provider Demographics
NPI:1578857967
Name:VIVENT HEALTH INC
Entity Type:Organization
Organization Name:VIVENT HEALTH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC VP
Authorized Official - Prefix:MR
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAULDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-525-5484
Mailing Address - Street 1:820 N PLANKINTON AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53203-1802
Mailing Address - Country:US
Mailing Address - Phone:414-225-1542
Mailing Address - Fax:414-225-1575
Practice Address - Street 1:445 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4107
Practice Address - Country:US
Practice Address - Phone:920-437-7400
Practice Address - Fax:920-437-1040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-03
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42228200Medicaid
WI42228200Medicaid