Provider Demographics
NPI:1528244613
Name:ROCK RIVER COMMUNITY CLINIC, INC
Entity type:Organization
Organization Name:ROCK RIVER COMMUNITY CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:ABE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-563-4372
Mailing Address - Street 1:520 HANDEYSIDE LN STE 4
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-1279
Mailing Address - Country:US
Mailing Address - Phone:920-563-4372
Mailing Address - Fax:920-463-4374
Practice Address - Street 1:520 HANDEYSIDE
Practice Address - Street 2:SUITE 4
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538
Practice Address - Country:US
Practice Address - Phone:920-563-4372
Practice Address - Fax:920-463-4374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-18
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38397100Medicaid