Healthcare Provider Details

I. General information

NPI: 1467841973
Provider Name (Legal Business Name): CROGHAN ADULT CARE FACILITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2015
Last Update Date: 01/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9837 MAIN STREET
CROGHAN NY
13327
US

IV. Provider business mailing address

1062 OAK FOREST DR
ONALASKA WI
54650-3489
US

V. Phone/Fax

Practice location:
  • Phone: 315-408-8973
  • Fax:
Mailing address:
  • Phone: 608-519-2306
  • Fax: 608-519-2307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMY E KEPLER
Title or Position: OWNER
Credential: MS/P
Phone: 608-475-0006