1023015948 NPI number — MARKESAN RESIDENT HOME INCORPORATED

Table of content: (NPI 1023015948)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023015948 NPI number — MARKESAN RESIDENT HOME INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARKESAN RESIDENT HOME INCORPORATED
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:
Provider Other Organization Name Type Code:
6
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:
1023015948
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1130 N MARGARET ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARKESAN
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53946-8516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-398-2751
Provider Business Mailing Address Fax Number:
920-398-3937

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1130 N MARGARET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARKESAN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53946-8516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-398-2751
Provider Business Practice Location Address Fax Number:
920-398-3937
Provider Enumeration Date:
07/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
OWNBY
Authorized Official First Name:
MIRIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
920-398-2751

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  3184 , 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: 20120200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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