=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568810422
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SCAL OF HOBART, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2016
-----------------------------------------------------
Last Update Date | 06/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 650 CENTENNIAL CENTRE BLVD
-----------------------------------------------------
City | HOBART
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54155-8989
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-544-5041
-----------------------------------------------------
Fax | 920-544-0857
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3232 N BALLARD RD SUITE 202
-----------------------------------------------------
City | APPLETON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54911-8804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-574-3833
-----------------------------------------------------
Fax | 920-574-3850
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MS. KATHERINE R. TEGEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 920-378-1913
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------