Provider Demographics
NPI:1427717115
Name:ROCK RIVER COMMUNITY CLINIC INC
Entity type:Organization
Organization Name:ROCK RIVER COMMUNITY CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:OLIVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:262-472-6839
Mailing Address - Street 1:1461 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHITEWATER
Mailing Address - State:WI
Mailing Address - Zip Code:53190-1568
Mailing Address - Country:US
Mailing Address - Phone:262-472-6839
Mailing Address - Fax:
Practice Address - Street 1:132 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3304
Practice Address - Country:US
Practice Address - Phone:920-206-7797
Practice Address - Fax:920-206-0870
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROCK RIVER COMMUNITY CLINIC INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-12-10
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health