Provider Demographics
NPI:1770620056
Name:NORTHREACH HEALTHCARE, LLC
Entity type:Organization
Organization Name:NORTHREACH HEALTHCARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:P
Authorized Official - Last Name:QUARTANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-732-2075
Mailing Address - Street 1:3130 SHORE DRIVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143
Mailing Address - Country:US
Mailing Address - Phone:715-735-0544
Mailing Address - Fax:715-735-0416
Practice Address - Street 1:3130 SHORE DRIVE
Practice Address - Street 2:SUITE 106
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143
Practice Address - Country:US
Practice Address - Phone:715-735-0544
Practice Address - Fax:715-735-0416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32894400Medicaid