Provider Demographics
NPI:1326235524
Name:COUNTY OF WAUSHARA
Entity type:Organization
Organization Name:COUNTY OF WAUSHARA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT CLERK
Authorized Official - Prefix:
Authorized Official - First Name:JEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-787-6550
Mailing Address - Street 1:205 W ELM ST
Mailing Address - Street 2:PO BOX 1230
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982
Mailing Address - Country:US
Mailing Address - Phone:920-787-6551
Mailing Address - Fax:920-787-0465
Practice Address - Street 1:380 S TOWNLINE RD
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-6900
Practice Address - Country:US
Practice Address - Phone:920-787-6550
Practice Address - Fax:920-787-0421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41762000Medicaid