Healthcare Provider Details

I. General information

NPI: 1376530592
Provider Name (Legal Business Name): NEW GLARUS HOME, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 2ND AVE
NEW GLARUS WI
53574-9776
US

IV. Provider business mailing address

600 2ND AVE
NEW GLARUS WI
53574-9776
US

V. Phone/Fax

Practice location:
  • Phone: 608-527-2126
  • Fax: 608-527-5365
Mailing address:
  • Phone: 608-527-2126
  • Fax: 608-527-5365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2605
License Number StateWI

VIII. Authorized Official

Name: MR. DAVID WICKLINE
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 608-527-2126