Provider Demographics
NPI:1962916650
Name:BOYS AND GIRLS CLUB OF PORTAGE COUNTY
Entity type:Organization
Organization Name:BOYS AND GIRLS CLUB OF PORTAGE COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SMILE CLUB COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:715-204-1180
Mailing Address - Street 1:PO BOX 171
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:941 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481
Practice Address - Country:US
Practice Address - Phone:715-204-1180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-17
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10047-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty