1144544354 NPI number — MARLA VISTA MANOR ASSISTED LIVING OF GREEN BAY, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144544354 NPI number — MARLA VISTA MANOR ASSISTED LIVING OF GREEN BAY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARLA VISTA MANOR ASSISTED LIVING OF GREEN BAY, LLC
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:
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:
1144544354
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
W3124 VAN ROY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APPLETON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54915-3982
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-574-3833
Provider Business Mailing Address Fax Number:
920-574-3850

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1006 N MILITARY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREEN BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54303-4412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-499-1119
Provider Business Practice Location Address Fax Number:
920-499-1191
Provider Enumeration Date:
03/16/2010

Additional Information

Authorized Official

Authorized Official Last Name:
TEGEN
Authorized Official First Name:
KATHERINE
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
920-378-5839

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , 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)





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