Provider Demographics
NPI:1750331807
Name:GRANT REGIONAL FAMILY PRACTICE
Entity Type:Organization
Organization Name:GRANT REGIONAL FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLAPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-723-3200
Mailing Address - Street 1:507 S MONROE ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:WI
Mailing Address - Zip Code:53813-2054
Mailing Address - Country:US
Mailing Address - Phone:608-723-3293
Mailing Address - Fax:608-723-3281
Practice Address - Street 1:507 S MONROE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:WI
Practice Address - Zip Code:53813-2054
Practice Address - Country:US
Practice Address - Phone:608-723-3293
Practice Address - Fax:608-723-3281
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRANT REGIONAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-11
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32765000Medicaid
WI32765000Medicaid