Provider Demographics
NPI:1194920058
Name:WILKINSON FOUNTAINS LEASE CO LLC
Entity type:Organization
Organization Name:WILKINSON FOUNTAINS LEASE CO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-747-3373
Mailing Address - Street 1:78 CENTENNIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-7900
Mailing Address - Country:US
Mailing Address - Phone:541-747-3373
Mailing Address - Fax:541-747-0673
Practice Address - Street 1:1201 HARTMAN LN
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-8402
Practice Address - Country:US
Practice Address - Phone:608-239-9282
Practice Address - Fax:618-222-9305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service