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General NPI Number Information
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NPI Number | 1124006739
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Entity Type | Organization
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Legal Business Name | ODD FELLOW REBEKAH HOME ASSOCIATION INC
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Dates
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Enumeration Date | 01/04/2006
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Last Update Date | 01/07/2013
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Provider Practice Location Address
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Address Line | 1207 S JACKSON ST
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City | GREEN BAY
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State | WI
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Zip | 54301-3037
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Country | US
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Telephone | 920-593-1640
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Fax | 920-435-5031
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Provider Business Mailing Address
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Address Line | 1207 SOUTH JACKSON STREET
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City | GREEN BAY
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State | WI
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Zip | 54301
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Country | US
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Telephone | 920-593-1640
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Fax | 920-435-5031
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Authorized Official
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Title or Position | CEO
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Name | MRS. CHARLENE EVERETT
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Credential | CEO, NHA, RN
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Telephone | 920-593-1640
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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 | 2544
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License Number State | WI
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