Healthcare Provider Details

I. General information

NPI: 1689660250
Provider Name (Legal Business Name): PINEVIEW NURSING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 01/27/2009
Certification Date:
Deactivation Date: 04/17/2008
Reactivation Date: 01/27/2009

III. Provider practice location address

400 COUNTY ROAD R
BLACK RIVER FALLS WI
54615-5129
US

IV. Provider business mailing address

307 MAIN ST
BLACK RIVER FALLS WI
54615-1744
US

V. Phone/Fax

Practice location:
  • Phone: 715-284-5396
  • Fax: 715-284-1502
Mailing address:
  • Phone: 715-284-0268
  • Fax: 715-284-0278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2440
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number2440
License Number StateWI

VIII. Authorized Official

Name: MRS. KYLE DENO
Title or Position: COUNTY CLERK
Credential: NHA
Phone: 715-284-0268