Provider Demographics
NPI:1538165766
Name:COUNTY OF LA CROSSE
Entity type:Organization
Organization Name:COUNTY OF LA CROSSE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AUDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-792-3713
Mailing Address - Street 1:300 4TH ST N
Mailing Address - Street 2:FL 2
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-3228
Mailing Address - Country:US
Mailing Address - Phone:608-785-9850
Mailing Address - Fax:608-785-9846
Practice Address - Street 1:300 4TH ST N
Practice Address - Street 2:FL 2
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-3228
Practice Address - Country:US
Practice Address - Phone:608-785-9850
Practice Address - Fax:608-785-9846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44000400251B00000X
WI41853100261QP2300X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41853100Medicaid
WI43082800Medicaid
WI43103500Medicaid
WI41520000Medicaid
WI44000400Medicaid
WI44000400Medicaid