Healthcare Provider Details

I. General information

NPI: 1235762881
Provider Name (Legal Business Name): IMR OAK CREEK OPCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2020
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 WEST HONADEL BOULEVARD
OAK CREEK WI
53154
US

IV. Provider business mailing address

1550 N NORTHWEST HWY STE 430
PARK RIDGE IL
60068-1411
US

V. Phone/Fax

Practice location:
  • Phone: 414-435-2005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: TIM FIELDS
Title or Position: CEO
Credential:
Phone: 833-944-6483