Provider Demographics
NPI:1629110077
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:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:LAURSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:715-468-7833
Mailing Address - Street 1:113 FOURTH AVE
Mailing Address - Street 2:P.O. BOX 300
Mailing Address - City:SHELL LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54871
Mailing Address - Country:US
Mailing Address - Phone:715-468-7833
Mailing Address - Fax:
Practice Address - Street 1:113 FOURTH AVE
Practice Address - Street 2:
Practice Address - City:SHELL LAKE
Practice Address - State:WI
Practice Address - Zip Code:54871
Practice Address - Country:US
Practice Address - Phone:715-468-7833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INDIANHEAD MEDICAL CENTER SHELL LAKE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-13
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI324251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41533400Medicaid
WI41533400Medicaid