Provider Demographics
NPI:1295853059
Name:COMMUNITY CARE OF PORTAGE COUNTY
Entity type:Organization
Organization Name:COMMUNITY CARE OF PORTAGE COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:CANALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-345-5800
Mailing Address - Street 1:817 WHITING AVE
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-5246
Mailing Address - Country:US
Mailing Address - Phone:715-345-5968
Mailing Address - Fax:715-345-5725
Practice Address - Street 1:817 WHITING AVE
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-5246
Practice Address - Country:US
Practice Address - Phone:715-345-5968
Practice Address - Fax:715-345-5725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI69005700Medicaid