Provider Demographics
NPI:1124157227
Name:WELLNESS CENTER OF DOOR COUNTY INC
Entity type:Organization
Organization Name:WELLNESS CENTER OF DOOR COUNTY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:J
Authorized Official - Last Name:GEIGER-BRONSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, APNP
Authorized Official - Phone:920-746-9444
Mailing Address - Street 1:312 N 5TH AVE
Mailing Address - Street 2:PO BOX 85
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-2102
Mailing Address - Country:US
Mailing Address - Phone:920-746-9444
Mailing Address - Fax:920-746-9466
Practice Address - Street 1:312 N 5TH AVE
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-2102
Practice Address - Country:US
Practice Address - Phone:920-746-9444
Practice Address - Fax:920-746-9466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QA0005X, 261QP2300X
WI1029-033363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility
Not Answered261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42011800Medicaid
WI00017004Medicare ID - Type UnspecifiedPRVOVIDER NUMBER