Healthcare Provider Details

I. General information

NPI: 1508920356
Provider Name (Legal Business Name): SACRED HEART REHABILITATION INSTITUTE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13111 N PORT WASHINGTON RD FL 2
MEQUON WI
53097-2416
US

IV. Provider business mailing address

PO BOX 773446
CHICAGO IL
60677-3446
US

V. Phone/Fax

Practice location:
  • Phone: 414-585-6884
  • Fax:
Mailing address:
  • Phone: 414-585-6884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number165
License Number StateWI

VIII. Authorized Official

Name: MICHAEL MCCULLOUGH
Title or Position: CFO
Credential:
Phone: 414-465-3736