NPIMap

Organization Active NPI

Black River Health Inc

Doing business as Black River Healthcare Clinic

  • Rural Health Clinic/Center
  • Black River Falls, WI
National Provider Identifier
1255183182
Registry record updated Apr 4, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
BLACK RIVER HEALTH INC
Doing business as
Black River Healthcare Clinic
Practice address
711 W Adams St
Black River Falls, WI 54615-9108
Phone
(715) 284-5361
NPI assigned
Apr 3, 2024
Last updated
Apr 4, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 4, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Catherine M Bukowski
Title
Cfo
Phone
(715) 284-3661

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

711 W Adams St
Black River Falls, WI 54615-9108

Mailing address

711 W Adams St
Black River Falls, WI 54615-5052
Phone (715) 284-5361

Other names 1

  • Black River Healthcare Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20070530000283 WI Part A Provider - Critical Access Hospital 3173431178 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Black River Falls, WI
O20240613001141 WI Part B Supplier - Clinic/Group Practice 3173431178 Receives reassigned benefits from 1 practitioner
Practice locations: Black River Falls, WI
O20250305000460 WI Part A Provider - Rural Health Clinic 3173431178 Practice locations: Black River Falls, WI

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1255183182. Details of each certification follow.

Hospital certification: CCN 52Z333

Legal name
BLACK RIVER HEALTH INC
Organization structure
CorporationNon-profit
Incorporated
Oct 8, 1965 in WI
Enrollment address
711 W Adams St
Black River Falls, WI 54615-9108
Other Hospital Practice Location

Rural health clinic certification: CCN 528658

Legal name
BLACK RIVER HEALTH INC
Doing business as
BLACK RIVER HEALTHCARE CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jul 23, 2025
Last certification
Jul 23, 2025
Ownership / control type
2B
Organization structure
CorporationNon-profit
Enrollment address
711 W Adams St
Black River Falls, WI 54615-9108
Related CCNs
521333

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 4

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
52D2264019Black River Healthcare Clinic -711 W Adams St, Black River Falls, WI 54615Certificate of waiverJul 7, 2028

National Provider Directory

National Provider Directory

Locations

311 County Road A
Ste 2
Black River Falls, WI 54615

Ownership & related parties

All disclosed owners & managing parties 11

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Thomas Stuart Walker Individual Corporate DirectorDirector Sep 28, 2021
Corporate DirectorBoard Member Sep 28, 2021
Timothy Tranberg Individual Corporate DirectorDirector Jun 23, 2022
Corporate DirectorBoard Member Jun 23, 2022
Michelle Clark-Forsting Individual Corporate DirectorDirector Dec 30, 2024
Corporate DirectorBoard Member Dec 30, 2024
Katherine Potter Individual Corporate DirectorDirector Jan 1, 2018
Corporate DirectorBoard Member May 11, 2017
Kirk Lane Individual Corporate DirectorDirector Dec 30, 2024
Corporate DirectorBoard Member Dec 30, 2024
Tammy Hernandez Individual Corporate DirectorVice President Finance Apr 23, 2026
W-2 Managing EmployeeVice President Finance Apr 23, 2026
Nicholas Kitowski Individual Corporate DirectorDirector Dec 30, 2024
Corporate DirectorBoard Member Dec 30, 2024
Wallace Apland Individual Corporate DirectorDirector Dec 19, 2023
Corporate DirectorBoard Member Dec 19, 2023
Carol a Martin Individual Corporate DirectorDirector Jan 1, 2021
Corporate DirectorBoard Member Jan 1, 2021
Carl Selvick Individual Corporate DirectorCeo Jun 6, 2022
W-2 Managing Employee Jun 6, 2022
Corporate OfficerCeo Jun 6, 2022
Christopher J Penza Individual Corporate OfficerDirector/Officer Jun 23, 2025
Corporate DirectorDirector/Officer Jun 23, 2025
Corporate DirectorBoard Member Jun 23, 2025

Owners & managing parties with NPI records 4

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 204

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 204

Affiliated clinicians 4

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1712102400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1743724800000",
    "number": "1255183182",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "711 W ADAMS ST",
            "city": "BLACK RIVER FALLS",
            "state": "WI",
            "postal_code": "546155052",
            "telephone_number": "715-284-5361"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "711 W ADAMS ST",
            "city": "BLACK RIVER FALLS",
            "state": "WI",
            "postal_code": "546159108",
            "telephone_number": "715-284-5361"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLACK RIVER HEALTH INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-04-03",
        "last_updated": "2025-04-04",
        "certification_date": "2025-04-04",
        "status": "A",
        "authorized_official_last_name": "BUKOWSKI",
        "authorized_official_first_name": "CATHERINE",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "715-284-3661"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Black River Healthcare Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Black River Falls, WI

Sources for this page

Verify at the official NPI Registry.