Provider Demographics
NPI:1679617831
Name:CLARK COUNTY
Entity Type:Organization
Organization Name:CLARK COUNTY
Other - Org Name:CLARK COUNTY PUBLIC HEALTH DEPARTMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEISCHOW
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:715-743-5116
Mailing Address - Street 1:517 COURT ST
Mailing Address - Street 2:ROOM #105
Mailing Address - City:NEILLSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54456-1971
Mailing Address - Country:US
Mailing Address - Phone:715-743-5105
Mailing Address - Fax:
Practice Address - Street 1:517 COURT ST
Practice Address - Street 2:ROOM #105
Practice Address - City:NEILLSVILLE
Practice Address - State:WI
Practice Address - Zip Code:54456-1971
Practice Address - Country:US
Practice Address - Phone:715-743-5105
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44011000Medicaid
WI42006800Medicaid
WI41851500Medicaid