Provider Demographics
NPI:1992079891
Name:SCHOOL SISTERS OF NOTRE DAME CENTRAL PACIFIC PROVINCE, INC.
Entity type:Organization
Organization Name:SCHOOL SISTERS OF NOTRE DAME CENTRAL PACIFIC PROVINCE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-782-9850
Mailing Address - Street 1:13105 WATERTOWN PLANK RD
Mailing Address - Street 2:
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-2213
Mailing Address - Country:US
Mailing Address - Phone:262-782-9850
Mailing Address - Fax:262-784-9788
Practice Address - Street 1:13105 WATERTOWN PLANK RD
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2213
Practice Address - Country:US
Practice Address - Phone:262-782-9850
Practice Address - Fax:262-784-9788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-24
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000086727Medicare UPIN