Provider Demographics
NPI:1083374359
Name:UNOLD, BEN R
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:R
Last Name:UNOLD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:682 N WALTON DR
Mailing Address - Street 2:
Mailing Address - City:WHITEWATER
Mailing Address - State:WI
Mailing Address - Zip Code:53190-2604
Mailing Address - Country:US
Mailing Address - Phone:262-458-2216
Mailing Address - Fax:
Practice Address - Street 1:551 N OAKHILL AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2712
Practice Address - Country:US
Practice Address - Phone:262-822-8820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-28
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home