Provider Demographics
NPI:1073809620
Name:BENEDICTINE LIVING COMMUNITY OF SPOONER
Entity Type:Organization
Organization Name:BENEDICTINE LIVING COMMUNITY OF SPOONER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MEYSEMBOURG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-635-1420
Mailing Address - Street 1:510 FIRST STREET
Mailing Address - Street 2:
Mailing Address - City:SPOONER
Mailing Address - State:WI
Mailing Address - Zip Code:54801
Mailing Address - Country:US
Mailing Address - Phone:715-635-1412
Mailing Address - Fax:715-635-7498
Practice Address - Street 1:510 FIRST STREET
Practice Address - Street 2:
Practice Address - City:SPOONER
Practice Address - State:WI
Practice Address - Zip Code:54801
Practice Address - Country:US
Practice Address - Phone:715-635-1412
Practice Address - Fax:715-635-7498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
525673Medicare Oscar/Certification