Healthcare Provider Details

I. General information

NPI: 1104814664
Provider Name (Legal Business Name): LEDGE VIEW NURSING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 DICKINSON RD
DE PERE WI
54115-8797
US

IV. Provider business mailing address

3737 DICKINSON RD
DE PERE WI
54115-8797
US

V. Phone/Fax

Practice location:
  • Phone: 920-336-7733
  • Fax: 920-339-7885
Mailing address:
  • Phone: 920-336-7733
  • Fax: 920-339-7885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number3105
License Number StateWI

VIII. Authorized Official

Name: MR. RONALD J DESOTELL
Title or Position: ADMINISTRATOR
Credential:
Phone: 920-336-7733