Provider Demographics
NPI:1801036447
Name:FOREST COUNTY POTAWATOMI HEALTH & WELLNESS
Entity type:Organization
Organization Name:FOREST COUNTY POTAWATOMI HEALTH & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRIBAL CHAIRMAN
Authorized Official - Prefix:MS
Authorized Official - First Name:NED
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-478-4824
Mailing Address - Street 1:PO BOX 396
Mailing Address - Street 2:
Mailing Address - City:CRANDON
Mailing Address - State:WI
Mailing Address - Zip Code:54520-0396
Mailing Address - Country:US
Mailing Address - Phone:715-478-4300
Mailing Address - Fax:715-478-4490
Practice Address - Street 1:8201 MISHKOSWEN DR
Practice Address - Street 2:
Practice Address - City:CRANDON
Practice Address - State:WI
Practice Address - Zip Code:54520-0396
Practice Address - Country:US
Practice Address - Phone:715-478-4300
Practice Address - Fax:715-478-4490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-23
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41752300Medicaid