Forest County Potawatomi Community

Primary specialty

Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X

Legal business name

FOREST COUNTY POTAWATOMI COMMUNITY

Doing business as

Potawatomi Health & Wellness Center

Practice address

8201 Mish Ko Swen Drive
Crandon, WI 54520-8631

Phone

(715) 478-4300

Fax

(715) 478-4300

NPI assigned

Aug 24, 2006

Last updated

Dec 9, 2020By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Mr. Ned Daniels

Title

Tribal Chairman

Phone

(715) 478-4824

Specialties & licenses 15

Addresses

Other names 1

• POTAWATOMI HEALTH & WELLNESS CENTER Doing business as

Medicare fee-for-service enrollment

Enrolled in WI3 enrollments

Enrollment records 3

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1285741306. Details of each certification follow.

• CCN 521819 Federally qualified health center · Active · Details

Federally qualified health center certification: CCN 521819

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

Other NPIs on the same Medicare enrollment 1

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

• Forest County Potawatomi Health & Wellness Center

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Crandon, WI
  • NPI 1376650499

  O20040228000204

  Same enrollment

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

CLIA laboratory certificates

Medicare medical equipment & supply locations

Locations

All disclosed owners & managing parties 5

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

Practitioners 28

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.

• Shelly Rae Buch, FNP

  • Family Nurse Practitioner
  • Florence, WI
  • NPI 1114106184
  Medicare reassignment Care Compare group NPD
• Steven P Kaplan, PH D

  • Psychologist
  • Appleton, WI
  • NPI 1548313869
  Medicare reassignment Care Compare group NPD
• Andrew D Kelly, PT

  • Physical Therapist
  • Crandon, WI
  • NPI 1508025347
  Medicare reassignment Care Compare group NPD
• Amanda C Lallensack, OD

  • Optometrist
  • Crandon, WI
  • NPI 1477178259
  Medicare reassignment Care Compare group NPD
• David C Larsen, DPM

  • Podiatrist
  • Woodruff, WI
  • NPI 1235125204
  Medicare reassignment Care Compare group NPD
• Shannon S Meyer, DPM

  • Podiatrist
  • Woodruff, WI
  • NPI 1316933542
  Medicare reassignment Care Compare group NPD
• Grant Andrew Packard, D.C.

  • Chiropractor
  • Green Bay, WI
  • NPI 1033488788
  Medicare reassignment Care Compare group NPD
• William R Pierre, OD TPA

  • Optometrist
  • Crandon, WI
  • NPI 1114935095
  Medicare reassignment Care Compare group NPD
• Jacklin A Sailo, FNP

  • Family Nurse Practitioner
  • Crandon, WI
  • NPI 1053619387
  Medicare reassignment Care Compare group NPD
• Bonnie M Samuelson, M.D.

  • Family Medicine Physician
  • Crandon, WI
  • NPI 1962432658
  Medicare reassignment Care Compare group NPD
• Kenneth L Schaufelberger, MD

  • Orthopaedic Surgery Physician
  • Neenah, WI
  • NPI 1790754810
  Medicare reassignment Care Compare group NPD
• Ashley Seiler, NP

  • Psychiatric/Mental Health Nurse Practitioner
  • Crandon, WI
  • NPI 1992015580
  Medicare reassignment Care Compare group NPD

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

{
    "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": [],
    "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"
        }
    ]
}

• Jolene A Derfus, SAC-IT
• Laura Donatelle, DNP APRN FNP
• Tanya Ann Doyle, LPCC
• Tracy Lynne Ferraro-Schumacher, MSW
• Forest County Department of Social Services
• Forest County Potawatomi Health & Wellness
• Forest County Potawatomi Health & Wellness Center
• Margaret Gother, PT
• Debra Ann Hilgart
• Michelle Lynn Huml, SACIT

• Federally Qualified Health Center (FQHC) in Crandon, WI
• Providers in Crandon, WI by specialty
• Federally Qualified Health Center (FQHC) in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 9, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.