Healthcare Provider Details

I. General information

NPI: 1306300694
Provider Name (Legal Business Name): DIVINE REHABILITATION AND NURSING AT FENNIMORE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2019
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 11TH ST
FENNIMORE WI
53809-1612
US

IV. Provider business mailing address

1632 61ST ST
BROOKLYN NY
11204-2109
US

V. Phone/Fax

Practice location:
  • Phone: 608-822-6100
  • Fax:
Mailing address:
  • Phone: 608-448-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ISAAK MARKOVITS
Title or Position: MANAGING MEMBER
Credential:
Phone: 718-753-0250