Provider Demographics
NPI:1649536442
Name:SOUTHWESTERN WI COMMUNTY ACTION PROGRAM
Entity type:Organization
Organization Name:SOUTHWESTERN WI COMMUNTY ACTION PROGRAM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR/NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYNE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BODDEN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:608-348-9766
Mailing Address - Street 1:275 W MAIN ST
Mailing Address - Street 2:PO BOX 704
Mailing Address - City:PLATTEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53818-3110
Mailing Address - Country:US
Mailing Address - Phone:608-348-9766
Mailing Address - Fax:608-348-3915
Practice Address - Street 1:275 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PLATTEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53818-3110
Practice Address - Country:US
Practice Address - Phone:608-348-9766
Practice Address - Fax:608-348-3915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41863200Medicaid
WI44008100Medicaid
WI42005400Medicaid
WI43973600Medicaid