Provider Demographics
NPI:1710139159
Name:CENTER FOR INDEPENDENT LIVING FOR WESTERN WISCONSIN
Entity Type:Organization
Organization Name:CENTER FOR INDEPENDENT LIVING FOR WESTERN WISCONSIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HR/FISCAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-233-1070
Mailing Address - Street 1:2920 SCHNEIDER AVE SE
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-2331
Mailing Address - Country:US
Mailing Address - Phone:715-233-1070
Mailing Address - Fax:715-233-1083
Practice Address - Street 1:2920 SCHNEIDER AVE SE
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-2331
Practice Address - Country:US
Practice Address - Phone:715-233-1070
Practice Address - Fax:715-233-1083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43105700Medicaid