Healthcare Provider Details

I. General information

NPI: 1205882149
Provider Name (Legal Business Name): MANOR CARE OF GREEN BAY WI (WEST) LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 SHAWANO AVE
GREEN BAY WI
54303-3216
US

IV. Provider business mailing address

333 N SUMMIT ST
TOLEDO OH
43604-2615
US

V. Phone/Fax

Practice location:
  • Phone: 920-499-5191
  • Fax: 920-499-8959
Mailing address:
  • Phone: 419-252-5500
  • Fax: 877-385-9446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2845
License Number StateWI

VIII. Authorized Official

Name: MR. MARTIN D ALLEN
Title or Position: DIRECTOR
Credential:
Phone: 419-252-5743