Provider Demographics
NPI:1689366759
Name:FAMILY HEALTH CENTER OF MARSHFIELD, INC.
Entity Type:Organization
Organization Name:FAMILY HEALTH CENTER OF MARSHFIELD, INC.
Other - Org Name:MEDFORD DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KYMBERLI
Authorized Official - Middle Name:
Authorized Official - Last Name:DARRACOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-654-5555
Mailing Address - Street 1:1307 N SAINT JOSEPH AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-1340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:843 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451-1307
Practice Address - Country:US
Practice Address - Phone:715-233-6800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-25
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)