Provider Demographics
NPI:1982812426
Name:CLARK COUNTY HEALTH CARE CENTER
Entity Type:Organization
Organization Name:CLARK COUNTY HEALTH CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHIMDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-229-2172
Mailing Address - Street 1:N13874 COUNTY ROAD O
Mailing Address - Street 2:
Mailing Address - City:WITHEE
Mailing Address - State:WI
Mailing Address - Zip Code:54498-9045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:W4266 STATE ROAD 29
Practice Address - Street 2:
Practice Address - City:OWEN
Practice Address - State:WI
Practice Address - Zip Code:54460-8932
Practice Address - Country:US
Practice Address - Phone:715-229-2172
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40608400Medicaid
WI29-027OtherO.T. LIC.