Provider Demographics
NPI:1447531827
Name:FIRST IMPRESSIONS OF MEDFORD
Entity type:Organization
Organization Name:FIRST IMPRESSIONS OF MEDFORD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:SEEHAFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-842-4649
Mailing Address - Street 1:PO BOX 48
Mailing Address - Street 2:
Mailing Address - City:SCHOFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54476-0048
Mailing Address - Country:US
Mailing Address - Phone:715-748-5435
Mailing Address - Fax:
Practice Address - Street 1:124 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451-1841
Practice Address - Country:US
Practice Address - Phone:715-748-5435
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-30
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38388300Medicaid