Healthcare Provider Details

I. General information

NPI: 1912991092
Provider Name (Legal Business Name): NAZARETH FACILITIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 JACKSON ST
STOUGHTON WI
53589-1520
US

IV. Provider business mailing address

12900 WHITEWATER DR STE 201
HOPKINS MN
55343-9407
US

V. Phone/Fax

Practice location:
  • Phone: 608-873-6448
  • Fax: 608-873-0829
Mailing address:
  • Phone: 763-537-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1159
License Number StateWI

VIII. Authorized Official

Name: DAVID L BRISCOE
Title or Position: CHIEF MANAGER
Credential:
Phone: 763-537-5700