Healthcare Provider Details

I. General information

NPI: 1932282555
Provider Name (Legal Business Name): SIMON OSHKOSH PROPERTIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 12/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 BOWEN ST
OSHKOSH WI
54901-2356
US

IV. Provider business mailing address

7400 NEW LA GRANGE RD SUITE 100
LOUISVILLE KY
40222-4870
US

V. Phone/Fax

Practice location:
  • Phone: 920-233-4011
  • Fax: 920-233-5177
Mailing address:
  • Phone: 502-429-8062
  • Fax: 502-429-5980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number3242
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number3242
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number3242
License Number StateWI

VIII. Authorized Official

Name: MR. STACEY PAUL ROGERS
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 502-429-8062