Healthcare Provider Details

I. General information

NPI: 1124006739
Provider Name (Legal Business Name): ODD FELLOW REBEKAH HOME ASSOCIATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 01/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 S JACKSON ST
GREEN BAY WI
54301-3037
US

IV. Provider business mailing address

1207 SOUTH JACKSON STREET
GREEN BAY WI
54301
US

V. Phone/Fax

Practice location:
  • Phone: 920-593-1640
  • Fax: 920-435-5031
Mailing address:
  • Phone: 920-593-1640
  • Fax: 920-435-5031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2544
License Number StateWI

VIII. Authorized Official

Name: MRS. CHARLENE EVERETT
Title or Position: CEO
Credential: CEO, NHA, RN
Phone: 920-593-1640