Provider Demographics
NPI:1750399630
Name:FOREST COUNTY POTAWATOMI COMMUNITY
Entity type:Organization
Organization Name:FOREST COUNTY POTAWATOMI COMMUNITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REVENUE CYCLE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:POLINSKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-478-4333
Mailing Address - Street 1:PO BOX 396
Mailing Address - Street 2:5409 EVERYBODYS ROAD
Mailing Address - City:CRANDON
Mailing Address - State:WI
Mailing Address - Zip Code:54520-0396
Mailing Address - Country:US
Mailing Address - Phone:715-478-4347
Mailing Address - Fax:715-478-4409
Practice Address - Street 1:8201 MISH KO SWEN DRIVE
Practice Address - Street 2:
Practice Address - City:CRANDON
Practice Address - State:WI
Practice Address - Zip Code:54520-8631
Practice Address - Country:US
Practice Address - Phone:715-478-4347
Practice Address - Fax:715-478-4409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2024-11-20
Deactivation Date:2008-12-04
Deactivation Code:
Reactivation Date:2024-11-20
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
No332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32956600Medicaid