Healthcare Provider Details

I. General information

NPI: 1164888525
Provider Name (Legal Business Name): 100 E. HIGHLAND DRIVE OPERATING COMPANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2016
Last Update Date: 04/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E HIGHLAND DR
OCONTO FALLS WI
54154-1001
US

IV. Provider business mailing address

1726 N BALLARD RD
APPLETON WI
54911-2444
US

V. Phone/Fax

Practice location:
  • Phone: 920-848-3272
  • Fax: 920-848-2516
Mailing address:
  • Phone: 920-991-9072
  • Fax: 920-749-4022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2727
License Number StateWI

VIII. Authorized Official

Name: KEVIN P BRESLIN
Title or Position: MANAGER
Credential:
Phone: 973-339-8892