Provider Demographics
NPI:1013093285
Name:BAD RIVER HEALTH CLINIC
Entity Type:Organization
Organization Name:BAD RIVER HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BIGBOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-682-7133
Mailing Address - Street 1:N87W16462 JACOBSON DR
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-2833
Mailing Address - Country:US
Mailing Address - Phone:262-255-1040
Mailing Address - Fax:262-255-4090
Practice Address - Street 1:1 MAPLE STREET
Practice Address - Street 2:
Practice Address - City:ODANAH
Practice Address - State:WI
Practice Address - Zip Code:54861
Practice Address - Country:US
Practice Address - Phone:715-682-7133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center