Provider Demographics
NPI:1619341815
Name:HEART FAILURE SURVIVAL CENTER OF AMERICA SC
Entity Type:Organization
Organization Name:HEART FAILURE SURVIVAL CENTER OF AMERICA SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROJECT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:QUAAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-330-7090
Mailing Address - Street 1:1281 MARINETTE AVE
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-2018
Mailing Address - Country:US
Mailing Address - Phone:715-330-7090
Mailing Address - Fax:715-732-0828
Practice Address - Street 1:1281 MARINETTE AVE
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-2018
Practice Address - Country:US
Practice Address - Phone:715-330-7090
Practice Address - Fax:715-732-0828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-25
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47840-20207RC0000X
363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100053346Medicaid