1316952062 NPI number — MASONIC CENTER FOR HEALTH AND REHAB INC.

Table of content: (NPI 1316952062)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316952062 NPI number — MASONIC CENTER FOR HEALTH AND REHAB INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MASONIC CENTER FOR HEALTH AND REHAB INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MASONIC HEALTHCARE CENTER INC.
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316952062
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
410 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOUSMAN
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53118-9348
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-965-2111
Provider Business Mailing Address Fax Number:
262-965-5553

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUSMAN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53118-9348
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-965-2111
Provider Business Practice Location Address Fax Number:
262-965-4053
Provider Enumeration Date:
07/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FREUCK
Authorized Official First Name:
JEAN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
262-965-7203

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  2869 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 20118900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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