Healthcare Provider Details

I. General information

NPI: 1558409227
Provider Name (Legal Business Name): COUNTRYVIEW GROUP HOMES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 10/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N112W12850 MEQUON RD
GERMANTOWN WI
53022-3624
US

IV. Provider business mailing address

1538 W LIEBAU RD
MEQUON WI
53092-2621
US

V. Phone/Fax

Practice location:
  • Phone: 262-512-1177
  • Fax: 262-512-9404
Mailing address:
  • Phone: 262-243-5515
  • Fax: 262-243-5516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number StateWI

VIII. Authorized Official

Name: MRS. RUTH KANTROWITZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 262-243-5515