MEDICARE: DALLAS HEALTHCARE CENTER INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	3039	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396896643
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DALLAS HEALTHCARE CENTER INC.

Provider Business Mailing Address
First Line	:	104 E DALLAS ST
Second Line	:	P.O. BOX 220
City	:	DALLAS
State	:	WI
Zip	:	54733-9699
Country	:	US
Telephone Number	:	715-837-1222
Fax Number	:	715-837-1713

Provider Business Practice Location Address
First Line	:	104 E DALLAS ST
Second Line	:
City	:	DALLAS
State	:	WI
Zip	:	54733-9699
Country	:	US
Telephone Number	:	715-837-1222
Fax Number	:	715-837-1713

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	LEN F FAST
Credential	:
Telephone Number	:	715-837-1222

Provider Enumeration Date	:	01/15/2007
Last Update Date	:	07/11/2007

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