MEDICARE: NSH RIB LAKE LLC

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

General Provider Information

NPI Number	:	1831631704
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NSH RIB LAKE LLC

Provider Business Mailing Address
First Line	:	5150 N PORT WASHINGTON RD
Second Line	:	SUITE 260
City	:	GLENDALE
State	:	WI
Zip	:	53217-5474
Country	:	US
Telephone Number	:	414-962-5250
Fax Number	:	414-962-5251

Provider Business Practice Location Address
First Line	:	650 PEARL ST
Second Line	:
City	:	RIB LAKE
State	:	WI
Zip	:	54470-9322
Country	:	US
Telephone Number	:	715-427-5291
Fax Number	:	715-427-5848

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	JEFFREY CHARLES HOEHN
Credential	:
Telephone Number	:	414-962-5250

Provider Enumeration Date	:	11/09/2016
Last Update Date	:	12/29/2016

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