Provider Demographics
NPI:1639294168
Name:NORTHWEST PASSAGE LTD
Entity Type:Organization
Organization Name:NORTHWEST PASSAGE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:MAURER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-327-4322
Mailing Address - Street 1:203 UNITED WAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:FREDERIC
Mailing Address - State:WI
Mailing Address - Zip Code:54837-8938
Mailing Address - Country:US
Mailing Address - Phone:715-327-4322
Mailing Address - Fax:715-327-8509
Practice Address - Street 1:7818 MOLINE ROAD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:WI
Practice Address - Zip Code:54893-8545
Practice Address - Country:US
Practice Address - Phone:715-866-8301
Practice Address - Fax:715-866-8374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI560014322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3181NOOtherBCBS OF MN
WI43015300Medicaid