Healthcare Provider Details

I. General information

NPI: 1568810422
Provider Name (Legal Business Name): SCAL OF HOBART, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 06/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 CENTENNIAL CENTRE BLVD
HOBART WI
54155-8989
US

IV. Provider business mailing address

3232 N BALLARD RD SUITE 202
APPLETON WI
54911-8804
US

V. Phone/Fax

Practice location:
  • Phone: 920-544-5041
  • Fax: 920-544-0857
Mailing address:
  • Phone: 920-574-3833
  • Fax: 920-574-3850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateWI

VIII. Authorized Official

Name: MS. KATHERINE R. TEGEN
Title or Position: MANAGER
Credential:
Phone: 920-378-1913