Healthcare Provider Details

I. General information

NPI: 1750378881
Provider Name (Legal Business Name): COLFAX HEALTH AND REHABILITATION CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 PARK DRIVE
COLFAX WI
54730-8902
US

IV. Provider business mailing address

110 PARK DRIVE
COLFAX WI
54730-8902
US

V. Phone/Fax

Practice location:
  • Phone: 715-962-3186
  • Fax: 715-962-3639
Mailing address:
  • Phone: 715-962-3186
  • Fax: 715-962-3639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1176
License Number StateWI

VII. Legacy identifiers

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

# 1
Identifier20156800
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer

VIII. Authorized Official

Name: MS. JILL RENEE GENGLER
Title or Position: ADMINISTRATOR
Credential: NHA
Phone: 715-962-3186