Healthcare Provider Details

I. General information

NPI: 1205840873
Provider Name (Legal Business Name): SPOONER HEALTH SYSTEM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 10/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 ASH ST
SPOONER WI
54801-1201
US

IV. Provider business mailing address

819 ASH ST
SPOONER WI
54801-1201
US

V. Phone/Fax

Practice location:
  • Phone: 715-635-2111
  • Fax: 715-635-7498
Mailing address:
  • Phone: 715-635-2111
  • Fax: 715-635-7498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number1164
License Number StateWI

VIII. Authorized Official

Name: LEN MEYSEMBOURG
Title or Position: NURSING HOME ADMINISTRATOR
Credential:
Phone: 715-635-2111