NPIMap

Organization Active NPI

Forest County Potawatomi Community

  • Federally Qualified Health Center (FQHC)
  • Crandon, WI
National Provider Identifier
1285741306
Registry record updated Dec 9, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
FOREST COUNTY POTAWATOMI COMMUNITY
Practice address
8201 Mish Ko Swen Drive
Crandon, WI 54520-8631
Phone
(715) 478-4300
Fax
(715) 478-4300
NPI assigned
Aug 24, 2006
Organization subpart
No

Authorized official

NPPES NPI Registry
Name
Mr. Ned Daniels
Title
Tribal Chairman
Phone
(715) 478-4824

Other NPIs on the same Medicare enrollment 1

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

Practitioners 28

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 28

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
52D0678081Forest Cty Potawatomi Health and Wellness Center8201 Mish Ko Swen Drive, Crandon, WI 54520AccreditationMay 17, 2028

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Forest County Potawatomi Community8201 Mish Ko Swen Dr, Crandon, WI 54520-8631(715) 478-4300 Canes and/or Crutches|Orthoses: Prefabricated (Non-Custom Fabricated)|Orthoses: Off-The-Shelf|Urological Supplies|Nebulizer Equipment and/or Supplies|Oxygen Equipment and/or Supplies|Surgical Dressings|Diabetic Shoes and Inserts Accepts assignmentParticipating since Jul 24, 2000

Medicare participation

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

Federally qualified health center certification: CCN 521819

Medicare enrollment files
Legal name
FOREST COUNTY POTAWATOMI COMMUNITY
Doing business as
POTAWATOMI HEALTH AND WELLNESS CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 24, 2000
Last certification
Jul 24, 2000
Ownership / control type
For profit – corporation
Organization structure
GovernmentNon-profit
Enrollment address
8201 Mish Ko Swen Dr
Crandon, WI 54520-8631

All disclosed owners & managing parties 5

Medicare enrollment files

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

NameRoleSinceShare
Sarah Genke Individual Corporate DirectorClinical Services Administrator May 1, 2018
W-2 Managing Employee May 1, 2018
Forest County Potawatomi Community Organization, Crandon, WI 5% Or Greater Direct Ownership Interest Jun 8, 2011
Operational/Managerial Control Jun 8, 2011 100%
Thomas W Boelter Individual Corporate DirectorHealth Division Administrator Aug 10, 2020
W-2 Managing Employee Aug 10, 2020
Ned Daniels Individual Corporate OfficerTribal Chairman Feb 12, 2018 100%
Melissa Zanzinger Individual W-2 Managing EmployeeFinance & Quality Director Jan 11, 2021

Medicare enrollment records 3

Medicare enrollment files
Enrollment IDStateProvider typePAC IDDetails
O20030908000029 WI Part a Provider - Federally Qualified Health Center (FQHC) 3375454689 Practice locations: Crandon, WI
O20040228000204 WI Part B Supplier - Clinic/Group Practice 3375454689 Receives reassigned benefits from 28 practitioners
1 other NPI on this enrollment
Practice locations: Crandon, WI
O20101021000752 WI DME Supplier - Physician - PodiatryDME Supplier - Indian Health Service Or Tribal Facility 3375454689 Practice locations: Crandon, WI

National Provider Directory

National Provider Directory

Locations

5415 Everybodys Rd
Crandon, WI 54520

Specialties & licenses 15

NPPES NPI Registry
Specialty (taxonomy)CodeLicenseStatePrimary
Dietary ManagerGroup: 193200000X MULTI-SPECIALTY GROUP 132700000X
NutritionistGroup: 193200000X MULTI-SPECIALTY GROUP 133N00000X
Pediatrics PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208000000X
Community Health Clinic/Center 261QC1500X
Dental Clinic/Center 261QD0000X
Federally Qualified Health Center (FQHC) 261QF0400X WI Primary
Hearing and Speech Clinic/Center 261QH0700X
Podiatric Clinic/Center 261QP1100X
Radiology Clinic/Center 261QR0200X
Mammography Clinic/Center 261QR0206X
Clinical Medical Laboratory 291U00000X
Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy 332800000X
Durable Medical Equipment & Medical Supplies 332B00000X
Eyewear Supplier 332H00000X
Hearing Aid Equipment 332S00000X

Addresses

NPPES NPI Registry

Primary practice location

8201 Mish Ko Swen Drive
Crandon, WI 54520-8631

Mailing address

PO Box 396
Crandon, WI 54520-0396
Phone (715) 478-4300

Other identifiers 10

NPPES NPI Registry
IdentifierTypeStateIssuer
391235059016OtherWIBLUE CROSS BLUE SHIELD
41752300OtherWIDURABLE MEDICAL EQUIPMENT
42182600OtherWIAODA CLINIC
32956600MedicaidWI
42182600OtherWIMENTAL HEALTH
DA0385OtherWIRAILROAD MEDICARE
42182600MedicaidWI
44006100OtherWIPRENATAL CARE
44006100MedicaidWI
41752300MedicaidWI

Other names 1

NPPES NPI Registry
  • POTAWATOMI HEALTH & WELLNESS CENTER Doing business as

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Dec 9, 2020.

{
    "created_epoch": "1156377600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1607472000000",
    "number": "1285741306",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 396",
            "city": "CRANDON",
            "state": "WI",
            "postal_code": "545200396",
            "telephone_number": "715-478-4300",
            "fax_number": "715-478-4490"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8201 MISH KO SWEN DRIVE",
            "city": "CRANDON",
            "state": "WI",
            "postal_code": "545208631",
            "telephone_number": "715-478-4300",
            "fax_number": "715-478-4300"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FOREST COUNTY POTAWATOMI COMMUNITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-24",
        "last_updated": "2020-12-09",
        "certification_date": "2020-12-09",
        "status": "A",
        "authorized_official_last_name": "DANIELS",
        "authorized_official_first_name": "NED",
        "authorized_official_title_or_position": "TRIBAL CHAIRMAN",
        "authorized_official_telephone_number": "715-478-4824",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "132700000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dietary Manager",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "133N00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nutritionist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "WI",
            "license": null,
            "primary": true
        },
        {
            "code": "261QH0700X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Hearing and Speech",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QP1100X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Podiatric",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR0200X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Radiology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR0206X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Radiology, Mammography",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "332800000X",
            "taxonomy_group": "",
            "desc": "Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "332H00000X",
            "taxonomy_group": "",
            "desc": "Eyewear Supplier",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "332S00000X",
            "taxonomy_group": "",
            "desc": "Hearing Aid Equipment",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "391235059016",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DURABLE MEDICAL EQUIPMENT",
            "identifier": "41752300",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AODA CLINIC",
            "identifier": "42182600",
            "state": "WI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "32956600",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MENTAL HEALTH",
            "identifier": "42182600",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "DA0385",
            "state": "WI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "42182600",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PRENATAL CARE",
            "identifier": "44006100",
            "state": "WI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "44006100",
            "state": "WI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "41752300",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "POTAWATOMI HEALTH & WELLNESS CENTER",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "POTAWATOMI HEALTH & WELLNESS CENTER",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Crandon, WI

Sources for this page

Verify at the official NPI Registry.