Provider Demographics
NPI:1982901088
Name:ST. VINCENT DE PAUL OF SAUK PRAIRIE/ ROXBURY, INC
Entity Type:Organization
Organization Name:ST. VINCENT DE PAUL OF SAUK PRAIRIE/ ROXBURY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:FABISIAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-643-8905
Mailing Address - Street 1:815 19TH ST
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU SAC
Mailing Address - State:WI
Mailing Address - Zip Code:53578-1195
Mailing Address - Country:US
Mailing Address - Phone:608-643-8905
Mailing Address - Fax:
Practice Address - Street 1:1906 NORTH ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU SAC
Practice Address - State:WI
Practice Address - Zip Code:53578-1148
Practice Address - Country:US
Practice Address - Phone:608-643-8905
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-25
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty