1790785475 NPI number — BIRCH HILL CARE CENTER 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 1790785475 NPI number — BIRCH HILL CARE CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BIRCH HILL CARE CENTER 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:
1790785475
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1726 N BALLARD 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:
54911-2444
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-991-9072
Provider Business Mailing Address Fax Number:
920-749-4021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1475 BIRCH HILL LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHAWANO
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54166-3707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-526-3161
Provider Business Practice Location Address Fax Number:
715-524-5896
Provider Enumeration Date:
07/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PARKINS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
920-364-9754

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  2895 , 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: 20192200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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