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General NPI Number Information
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NPI Number | 1093170813
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Entity Type | Organization
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Legal Business Name | CRYSTAL FOUNTAINS REHABILITATION CENTER LLC
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Dates
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Enumeration Date | 12/21/2015
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Last Update Date | 12/21/2015
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Provider Practice Location Address
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Address Line | 3737 DICKINSON RD
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City | DE PERE
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State | WI
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Zip | 54115-8797
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Country | US
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Telephone | 920-336-7733
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Fax | 920-336-3697
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Provider Business Mailing Address
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Address Line | 3450 BRIDLEWOOD DR
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City | PLOVER
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State | WI
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Zip | 54467-3892
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Country | US
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Telephone | 715-342-9100
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Fax | 715-342-9101
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Authorized Official
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Title or Position | DIRECTOR OF OPERATIONS
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Name | KAREN MARIE TRZEBIATOWSKI
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Credential | RN
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Telephone | 715-340-1479
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 3105
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License Number State | WI
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