Healthcare Provider Details

I. General information

NPI: 1154299386
Provider Name (Legal Business Name): TP KCB HARBOUR VILLAGE OPCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2025
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 MOCKINGBIRD LN
GREENDALE WI
53129-1459
US

IV. Provider business mailing address

2265 E MURRAY HOLLADAY RD
HOLLADAY UT
84117-5379
US

V. Phone/Fax

Practice location:
  • Phone: 414-421-9600
  • Fax:
Mailing address:
  • Phone: 917-921-0531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW MCCONKIE
Title or Position: MANAGER
Credential:
Phone: 917-921-0531