Healthcare Provider Details

I. General information

NPI: 1548337603
Provider Name (Legal Business Name): MEQUON JEWISH CAMPUS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10995 N MARKET ST
MEQUON WI
53092-4952
US

IV. Provider business mailing address

1414 N PROSPECT AVE
MILWAUKEE WI
53202-3018
US

V. Phone/Fax

Practice location:
  • Phone: 262-478-1500
  • Fax: 262-478-0355
Mailing address:
  • Phone: 262-478-1500
  • Fax: 262-478-0355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number5017
License Number StateWI

VIII. Authorized Official

Name: MR. PAUL FISCUS
Title or Position: ADMINISTRATOR
Credential:
Phone: 262-478-1501