1417466152 NPI number — NORTH OAK HEALTH CARE WISTERIA HAUS LLC

Table of content: (NPI 1417466152)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417466152 NPI number — NORTH OAK HEALTH CARE WISTERIA HAUS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH OAK HEALTH CARE WISTERIA HAUS 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:
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:
1417466152
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1025 SHERMER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTHBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60062-3730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2741 45TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TWO RIVERS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54241-1002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-612-0750
Provider Business Practice Location Address Fax Number:
920-794-4057
Provider Enumeration Date:
09/26/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MASCHOFF
Authorized Official First Name:
DEAN
Authorized Official Middle Name:
CARL
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
847-612-0750

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 313M00000X , with the licence number: 0016823 , 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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