Healthcare Provider Details

I. General information

NPI: 1336057363
Provider Name (Legal Business Name): DEER DALE HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 N 8TH ST
MOUNT HOREB WI
53572-1872
US

IV. Provider business mailing address

407 N 8TH ST
MOUNT HOREB WI
53572-1872
US

V. Phone/Fax

Practice location:
  • Phone: 608-437-5511
  • Fax: 608-470-4065
Mailing address:
  • Phone: 608-437-5511
  • Fax: 608-470-4065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: SOON BURNAM
Title or Position: SECRETARY
Credential:
Phone: 949-540-1249