Provider Demographics
NPI:1861219081
Name:JEFFERSON COUNTY CLTS WAIVER
Entity type:Organization
Organization Name:JEFFERSON COUNTY CLTS WAIVER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPUTY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BELLFORD
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:920-674-3105
Mailing Address - Street 1:1541 ANNEX RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:WI
Mailing Address - Zip Code:53549-9803
Mailing Address - Country:US
Mailing Address - Phone:920-674-3105
Mailing Address - Fax:
Practice Address - Street 1:1541 ANNEX RD
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:WI
Practice Address - Zip Code:53549-9803
Practice Address - Country:US
Practice Address - Phone:920-674-3105
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEFFERSON COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management