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General NPI Number Information
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NPI Number | 1144544354
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Entity Type | Organization
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Legal Business Name | MARLA VISTA MANOR ASSISTED LIVING OF GREEN BAY, LLC
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Dates
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Enumeration Date | 03/16/2010
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Last Update Date | 03/16/2010
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Provider Practice Location Address
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Address Line | 1006 N MILITARY AVE
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City | GREEN BAY
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State | WI
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Zip | 54303-4412
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Country | US
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Telephone | 920-499-1119
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Fax | 920-499-1191
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Provider Business Mailing Address
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Address Line | W3124 VAN ROY RD
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City | APPLETON
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State | WI
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Zip | 54915-3982
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Country | US
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Telephone | 920-574-3833
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Fax | 920-574-3850
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Authorized Official
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Title or Position | MANAGER
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Name | KATHERINE R. TEGEN
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Credential |
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Telephone | 920-378-5839
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State | WI
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