Provider Demographics
NPI:1285922971
Name:BLANDINE HOUSE INC
Entity type:Organization
Organization Name:BLANDINE HOUSE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:COLWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-922-9487
Mailing Address - Street 1:25 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-3501
Mailing Address - Country:US
Mailing Address - Phone:920-922-9487
Mailing Address - Fax:920-922-9184
Practice Address - Street 1:25 N PARK AVE
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-3501
Practice Address - Country:US
Practice Address - Phone:920-922-9487
Practice Address - Fax:920-922-9184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1068-800324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility