Healthcare Provider Details

I. General information

NPI: 1922001247
Provider Name (Legal Business Name): MARYWOOD CONVALESCENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 12/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 N 4TH AVE
WAUSAU WI
54401-1910
US

IV. Provider business mailing address

1995 E RUM RIVER DR S
CAMBRIDGE MN
55008-2656
US

V. Phone/Fax

Practice location:
  • Phone: 715-675-9451
  • Fax: 715-675-4051
Mailing address:
  • Phone: 763-689-1162
  • Fax: 763-689-6117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2674
License Number StateWI

VIII. Authorized Official

Name: KEVIN J RYMANOWSKI
Title or Position: SVP FINANCE
Credential:
Phone: 763-689-1162