Provider Demographics
NPI:1780952549
Name:NORTHREACH HEALTHCARE, LLC
Entity type:Organization
Organization Name:NORTHREACH HEALTHCARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:HIPKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-732-2078
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7226
Mailing Address - Fax:920-445-7229
Practice Address - Street 1:1100 10TH ST
Practice Address - Street 2:
Practice Address - City:MENOMINEE
Practice Address - State:MI
Practice Address - Zip Code:49858-3027
Practice Address - Country:US
Practice Address - Phone:920-445-7226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHREACH HEALTHCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-08
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 261QR1300X
MI23D09382233291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23D0382233OtherCLINIC CLIA
MI23-3861OtherRURAL HEALTH
MI23D0382233OtherCLINIC CLIA