Provider Demographics
NPI:1003842873
Name:CLEARWATER CARE CENTER, LLC
Entity Type:Organization
Organization Name:CLEARWATER CARE CENTER, LLC
Other - Org Name:AMERICAN EAGLE NURSING HOME COMPANY OF EAU CLAIRE, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT AND COO
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLASS
Authorized Official - Middle Name:B
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-647-9004
Mailing Address - Street 1:121 SOUTH WATER AVENUE
Mailing Address - Street 2:
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-2902
Mailing Address - Country:US
Mailing Address - Phone:615-989-7881
Mailing Address - Fax:715-831-7022
Practice Address - Street 1:2120 HEIGHTS DRIVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701
Practice Address - Country:US
Practice Address - Phone:715-832-1681
Practice Address - Fax:715-831-7022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3224314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100007803Medicaid
WI100007803Medicaid