Provider Demographics
NPI:1447543434
Name:VIVENT HEALTH INC
Entity type:Organization
Organization Name:VIVENT HEALTH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC VP
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:DYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-525-5484
Mailing Address - Street 1:820 N PLANKINTON AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53203-1802
Mailing Address - Country:US
Mailing Address - Phone:414-225-1542
Mailing Address - Fax:414-225-1575
Practice Address - Street 1:1105 GRAND AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:SCHOFIELD
Practice Address - State:WI
Practice Address - Zip Code:54476-1168
Practice Address - Country:US
Practice Address - Phone:715-355-6867
Practice Address - Fax:715-355-0640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-24
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42228200Medicaid