=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194956284
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EHF LAKE COUNTRY SNF OP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2009
-----------------------------------------------------
Last Update Date | 06/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 W MICHIGAN ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53203-2903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-908-8119
-----------------------------------------------------
Fax | 414-908-7105
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2195 N SUMMIT VILLAGE WAY
-----------------------------------------------------
City | OCONOMOWOC
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53066-8675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-255-0096
-----------------------------------------------------
Fax | 262-567-5093
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF COMPLIANCE
-----------------------------------------------------
Name | MS. DONNA J THIEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 414-908-8119
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------