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General NPI Number Information
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NPI Number | 1154567469
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Entity Type | Organization
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Legal Business Name | MAIN STREET QUARTERS
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Dates
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Enumeration Date | 12/17/2008
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Last Update Date | 12/17/2008
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Provider Practice Location Address
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Address Line | 354 N MAIN ST
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City | OREGON
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State | WI
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Zip | 53575-1426
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Country | US
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Telephone | 608-835-3535
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Fax |
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Provider Business Mailing Address
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Address Line | 354 N MAIN ST
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City | OREGON
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State | WI
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Zip | 53575-1426
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | RICK SCOLLON
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Credential |
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Telephone | 608-835-3535
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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 | 110279
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License Number State | WI
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