Healthcare Provider Details

I. General information

NPI: 1235474792
Provider Name (Legal Business Name): MANITOWOC HEALTH & REHABILITATION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2012
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 S ALVERNO RD
MANITOWOC WI
54220-9208
US

IV. Provider business mailing address

2021 S ALVERNO RD
MANITOWOC WI
54220-9208
US

V. Phone/Fax

Practice location:
  • Phone: 920-683-4100
  • Fax:
Mailing address:
  • Phone: 920-683-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number20200900
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier261752627
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer

VIII. Authorized Official

Name: BEN PRINCE
Title or Position: ADMINISTRATOR
Credential:
Phone: 920-683-4100