Healthcare Provider Details

I. General information

NPI: 1093700734
Provider Name (Legal Business Name): KINNIC LONG TERM CARE FACILITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1663 E DIVISION ST
RIVER FALLS WI
54022-1571
US

IV. Provider business mailing address

345 FRENETTE DR
CHIPPEWA FALLS WI
54729-3372
US

V. Phone/Fax

Practice location:
  • Phone: 715-426-6000
  • Fax: 715-426-6007
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number3095
License Number StateWI

VIII. Authorized Official

Name: MR. DENNIS L HEYDE
Title or Position: PRESIDENT
Credential:
Phone: 715-726-9094