Provider Demographics
NPI:1548710627
Name:GUNDERSEN CLINIC LTD
Entity type:Organization
Organization Name:GUNDERSEN CLINIC LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-775-6369
Mailing Address - Street 1:528 CASS ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4507
Mailing Address - Country:US
Mailing Address - Phone:608-784-9922
Mailing Address - Fax:608-784-2212
Practice Address - Street 1:528 CASS ST
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4507
Practice Address - Country:US
Practice Address - Phone:608-784-9922
Practice Address - Fax:608-784-2212
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GUNDERSEN CLINIC LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-12
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X
WI9419-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100063781Medicaid
MN1548710627Medicaid
2163891OtherPK
2163891OtherPK