Healthcare Provider Details

I. General information

NPI: 1518304104
Provider Name (Legal Business Name): SPRINGBROOK COMMUNITY ASSISTED LIVING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2013
Last Update Date: 05/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

861 CRITTER CT
ONALASKA WI
54650-8689
US

IV. Provider business mailing address

861 CRITTER CT
ONALASKA WI
54650-8689
US

V. Phone/Fax

Practice location:
  • Phone: 608-783-2292
  • Fax:
Mailing address:
  • Phone: 608-783-2292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number0013768
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number0011819
License Number StateWI

VIII. Authorized Official

Name: ANN E SIMONSON
Title or Position: OWNER
Credential:
Phone: 608-630-9535