Healthcare Provider Details

I. General information

NPI: 1609219195
Provider Name (Legal Business Name): SHEBOYGAN SENIOR COMMUNITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

5314 GROVE RD
REEDSVILLE WI
54230-9131
US

IV. Provider business mailing address

5314 GROVE RD
REEDSVILLE WI
54230-9131
US

V. Phone/Fax

Practice location:
  • Phone: 920-228-0464
  • Fax: 920-459-0638
Mailing address:
  • Phone: 920-228-0464
  • Fax: 920-459-0638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number4640-27
License Number StateWI

VIII. Authorized Official

Name: JOAN KLEIST
Title or Position: DO
Credential:
Phone: 920-458-2137