Provider Demographics
NPI:1164965257
Name:CHP SHOREWOOD WI TENANT CORP
Entity Type:Organization
Organization Name:CHP SHOREWOOD WI TENANT CORP
Other - Org Name:HARBORCHASE OF SHOREWOOD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO OF MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-492-5002
Mailing Address - Street 1:1440 HIGHWAY A1A
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32963-2310
Mailing Address - Country:US
Mailing Address - Phone:772-492-5002
Mailing Address - Fax:772-492-5005
Practice Address - Street 1:1111 E CAPITOL DR
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:WI
Practice Address - Zip Code:53211-1810
Practice Address - Country:US
Practice Address - Phone:414-436-0311
Practice Address - Fax:414-436-0312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-22
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0015905310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility