Healthcare Provider Details

I. General information

NPI: 1508015884
Provider Name (Legal Business Name): ST. PAUL ELDER SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2008
Last Update Date: 09/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 E 14TH ST
KAUKAUNA WI
54130-3304
US

IV. Provider business mailing address

316 E 14TH ST
KAUKAUNA WI
54130-3304
US

V. Phone/Fax

Practice location:
  • Phone: 920-766-6020
  • Fax: 920-759-1937
Mailing address:
  • Phone: 920-766-6020
  • Fax: 920-759-1937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number4606027
License Number StateWI

VIII. Authorized Official

Name: MRS. LESLIE AARON MATZ
Title or Position: COTA
Credential: COTA
Phone: 920-766-6020