Healthcare Provider Details

I. General information

NPI: 1730187238
Provider Name (Legal Business Name): TDR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 01/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 WILLOW ST
PESHTIGO WI
54157-1165
US

IV. Provider business mailing address

261 FRENCH ST
PESHTIGO WI
54157-1217
US

V. Phone/Fax

Practice location:
  • Phone: 715-582-3962
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number3118
License Number StateWI

VIII. Authorized Official

Name: NEIL JOHNSON
Title or Position: TREASURER
Credential:
Phone: 715-582-2200