Healthcare Provider Details

I. General information

NPI: 1235458894
Provider Name (Legal Business Name): LAKEWOOD ASSISTED LIVING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2010
Last Update Date: 05/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17185 FLYNN LN
LAKEWOOD WI
54138-9593
US

IV. Provider business mailing address

W3124 VAN ROY RD
APPLETON WI
54915-3982
US

V. Phone/Fax

Practice location:
  • Phone: 715-276-1680
  • Fax:
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: KATHERINE R TEGEN
Title or Position: MANAGER
Credential:
Phone: 920-378-5839