Healthcare Provider Details

I. General information

NPI: 1295178713
Provider Name (Legal Business Name): GRAVES ENTERPRISES INC D/B/A OREGON MANOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2013
Last Update Date: 12/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

354 N MAIN ST
OREGON WI
53575-1426
US

IV. Provider business mailing address

354 N MAIN ST
OREGON WI
53575-1426
US

V. Phone/Fax

Practice location:
  • Phone: 608-835-3535
  • Fax: 608-835-3890
Mailing address:
  • Phone: 608-835-3535
  • Fax: 608-835-3890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number20100100
License Number StateWI

VIII. Authorized Official

Name: THOMAS L GRAVES
Title or Position: PRESIDENT
Credential: LNHA
Phone: 608-835-3535