Healthcare Provider Details

I. General information

NPI: 1740270735
Provider Name (Legal Business Name): ST. JOSEPH'S HOME OF OUR LADY OF MT CARMEL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 08/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9244 29TH AVE
KENOSHA WI
53143-6602
US

IV. Provider business mailing address

9244 29TH AVE
KENOSHA WI
53143-6602
US

V. Phone/Fax

Practice location:
  • Phone: 262-694-0080
  • Fax: 262-925-8137
Mailing address:
  • Phone: 262-694-0080
  • Fax: 262-925-8137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2332
License Number StateWI

VIII. Authorized Official

Name: SUSIE K EIDSOR
Title or Position: BUSINESS MANAGER
Credential:
Phone: 262-925-8104