Healthcare Provider Details

I. General information

NPI: 1700513561
Provider Name (Legal Business Name): WATERFALL HEALTH OF ALGOMA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2022
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 FREMONT ST
ALGOMA WI
54201-1948
US

IV. Provider business mailing address

1510 FREMONT ST
ALGOMA WI
54201-1948
US

V. Phone/Fax

Practice location:
  • Phone: 920-487-5511
  • Fax: 920-487-2668
Mailing address:
  • Phone: 920-487-5511
  • Fax: 920-487-2668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: SAM FOLLMAN
Title or Position: OWNER
Credential:
Phone: 920-487-5511