Provider Demographics
NPI:1053540856
Name:NORTH COUNTRY INDEPENDENT LIVING
Entity type:Organization
Organization Name:NORTH COUNTRY INDEPENDENT LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:NOUSAINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-392-9118
Mailing Address - Street 1:2231 CATLIN AVE
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-5137
Mailing Address - Country:US
Mailing Address - Phone:715-392-9118
Mailing Address - Fax:715-392-4636
Practice Address - Street 1:2231 CATLIN AVE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5137
Practice Address - Country:US
Practice Address - Phone:715-392-9118
Practice Address - Fax:715-392-4636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-14
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43112700Medicaid