Provider Demographics
NPI:1710018817
Name:THEDACARE MEDICAL CENTER - WILD ROSE, INC
Entity Type:Organization
Organization Name:THEDACARE MEDICAL CENTER - WILD ROSE, INC
Other - Org Name:WAUSHARA FAMILY PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC MANAGER/ DIRECTOR OF NU
Authorized Official - Prefix:
Authorized Official - First Name:JENIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:DANZEISEN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:920-622-5564
Mailing Address - Street 1:PO BOX 314
Mailing Address - Street 2:
Mailing Address - City:WILD ROSE
Mailing Address - State:WI
Mailing Address - Zip Code:54984-0314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 GROVE AVE
Practice Address - Street 2:
Practice Address - City:WILD ROSE
Practice Address - State:WI
Practice Address - Zip Code:54984-6901
Practice Address - Country:US
Practice Address - Phone:920-622-6013
Practice Address - Fax:920-774-1026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47322-20332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
2115407OtherPK