Healthcare Provider Details

I. General information

NPI: 1023451523
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

1702 29TH ST
TWO RIVERS WI
54241-2010
US

IV. Provider business mailing address

1702 29TH ST
TWO RIVERS WI
54241-2010
US

V. Phone/Fax

Practice location:
  • Phone: 920-242-4727
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1575-19
License Number StateWI

VIII. Authorized Official

Name: AMY VAN RUDEN
Title or Position: REGINAL MANAGER
Credential: OTR
Phone: 242-939-5296