Healthcare Provider Details

I. General information

NPI: 1659736478
Provider Name (Legal Business Name): CRYSTAL FOUNTAINS REHABILITATION CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2015
Last Update Date: 12/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 SOUTH CLAY ST
GREEN BAY WI
54301-3807
US

IV. Provider business mailing address

3450 BRIDLEWOOD DR
PLOVER WI
54467-3892
US

V. Phone/Fax

Practice location:
  • Phone: 920-432-5231
  • Fax: 920-432-9881
Mailing address:
  • Phone: 715-342-9100
  • Fax: 715-342-9101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1134
License Number StateWI

VIII. Authorized Official

Name: KAREN TRZEBIATOWSKI
Title or Position: DIRECTOR OF OPERATIONS
Credential: RN
Phone: 715-340-1479