Healthcare Provider Details

I. General information

NPI: 1689878563
Provider Name (Legal Business Name): ELITE SENIOR LIVING - FOUNTAIN VIEW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 11/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 WOLVERTON AVE
RIPON WI
54971-1050
US

IV. Provider business mailing address

50 WOLVERTON AVE
RIPON WI
54971-1050
US

V. Phone/Fax

Practice location:
  • Phone: 920-748-5638
  • Fax:
Mailing address:
  • Phone: 920-748-5638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. JONATHAN HERATY
Title or Position: MANAGER
Credential:
Phone: 716-748-7880