Provider Demographics
NPI:1336505791
Name:1311 TYLER STREET OPERATING COMPANY, LLC
Entity Type:Organization
Organization Name:1311 TYLER STREET OPERATING COMPANY, LLC
Other - Org Name:ATRIUM POST ACUTE CARE OF BLACK RIVER FALLS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:BRESLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-339-8892
Mailing Address - Street 1:1726 N BALLARD RD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-2444
Mailing Address - Country:US
Mailing Address - Phone:920-991-9072
Mailing Address - Fax:920-749-4022
Practice Address - Street 1:1311 TYLER ST
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-1564
Practice Address - Country:US
Practice Address - Phone:715-284-4396
Practice Address - Fax:715-284-9580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-14
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3211314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1336505791Medicaid
WI525488Medicare Oscar/Certification
WI1336505791Medicaid