Provider Demographics
NPI:1780717801
Name:SAUK COUNTY
Entity type:Organization
Organization Name:SAUK COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BODENDEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-355-3290
Mailing Address - Street 1:505 BROADWAY
Mailing Address - Street 2:372
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913
Mailing Address - Country:US
Mailing Address - Phone:608-355-3290
Mailing Address - Fax:608-355-4329
Practice Address - Street 1:505 BROADWAY
Practice Address - Street 2:372
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913
Practice Address - Country:US
Practice Address - Phone:608-355-3290
Practice Address - Fax:608-355-4329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI102251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44004300Medicaid