Provider Demographics
| NPI: | 1285741306 |
|---|---|
| Name: | FOREST COUNTY POTAWATOMI COMMUNITY |
| Entity type: | Organization |
| Organization Name: | FOREST COUNTY POTAWATOMI COMMUNITY |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | TRIBAL CHAIRMAN |
| Authorized Official - Prefix: | MR |
| 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 MISH KO SWEN DRIVE |
| Practice Address - Street 2: | |
| Practice Address - City: | CRANDON |
| Practice Address - State: | WI |
| Practice Address - Zip Code: | 54520-8631 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 715-478-4300 |
| Practice Address - Fax: | 715-478-4300 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-08-24 |
| Last Update Date: | 2020-12-09 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 132700000X, 133N00000X, 208000000X, 261QC1500X, 261QD0000X, 261QH0700X, 261QP1100X, 261QR0200X, 261QR0206X, 291U00000X, 332800000X, 332B00000X, 332H00000X, 332S00000X | ||
| WI | 261QF0400X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 261QF0400X | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | |
| No | 132700000X | Dietary & Nutritional Service Providers | Dietary Manager | Group - Multi-Specialty | |
| No | 133N00000X | Dietary & Nutritional Service Providers | Nutritionist | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 261QC1500X | Ambulatory Health Care Facilities | Clinic/Center | Community Health | Group - Multi-Specialty |
| No | 261QD0000X | Ambulatory Health Care Facilities | Clinic/Center | Dental | |
| No | 261QH0700X | Ambulatory Health Care Facilities | Clinic/Center | Hearing and Speech | |
| No | 261QP1100X | Ambulatory Health Care Facilities | Clinic/Center | Podiatric | |
| No | 261QR0200X | Ambulatory Health Care Facilities | Clinic/Center | Radiology | |
| No | 261QR0206X | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography | |
| No | 291U00000X | Laboratories | Clinical Medical Laboratory | ||
| No | 332800000X | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy | ||
| No | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies | ||
| No | 332H00000X | Suppliers | Eyewear Supplier | ||
| No | 332S00000X | Suppliers | Hearing Aid Equipment |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| WI | 391235059016 | Other | BLUE CROSS BLUE SHIELD |
| WI | 41752300 | Other | DURABLE MEDICAL EQUIPMENT |
| WI | 42182600 | Other | AODA CLINIC |
| WI | 32956600 | Medicaid | |
| WI | 42182600 | Other | MENTAL HEALTH |
| WI | DA0385 | Other | RAILROAD MEDICARE |
| WI | 42182600 | Medicaid | |
| WI | 44006100 | Other | PRENATAL CARE |
| WI | 44006100 | Medicaid | |
| WI | 41752300 | Medicaid | |
| WI | 44006100 | Medicaid | |
| WI | 41752300 | Medicaid | |
| WI | 521819 | Medicare Oscar/Certification | |
| WI | 41752300 | Medicaid |
