Provider Demographics
NPI:1093170813
Name:CRYSTAL FOUNTAINS REHABILITATION CENTER LLC
Entity Type:Organization
Organization Name:CRYSTAL FOUNTAINS REHABILITATION CENTER LLC
Other - Org Name:LEDGEVIEW NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:TRZEBIATOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:715-340-1479
Mailing Address - Street 1:3450 BRIDLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PLOVER
Mailing Address - State:WI
Mailing Address - Zip Code:54467-3892
Mailing Address - Country:US
Mailing Address - Phone:715-342-9100
Mailing Address - Fax:715-342-9101
Practice Address - Street 1:3737 DICKINSON RD
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-8797
Practice Address - Country:US
Practice Address - Phone:920-336-7733
Practice Address - Fax:920-336-3697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3105314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20171900Medicaid
WI525515Medicare Oscar/Certification