Healthcare Provider Details

I. General information

NPI: 1790236966
Provider Name (Legal Business Name): DYCORA TRANSITIONAL HEALTH - GLENDALE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2016
Last Update Date: 01/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 W SILVER SPRING DR
GLENDALE WI
53209-4415
US

IV. Provider business mailing address

1300 W SILVER SPRING DR
GLENDALE WI
53209-4415
US

V. Phone/Fax

Practice location:
  • Phone: 414-228-8120
  • Fax:
Mailing address:
  • Phone: 414-228-8120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARY HAWKINS
Title or Position: EXECUTIVE
Credential:
Phone: 414-228-8120