Provider Demographics
NPI:1336667526
Name:COOPERLEAF MANAGEMENT GROUP
Entity Type:Organization
Organization Name:COOPERLEAF MANAGEMENT GROUP
Other - Org Name:COPPERLEAF VILLAGE OF RIPON
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDYKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-254-4357
Mailing Address - Street 1:1077 WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481
Mailing Address - Country:US
Mailing Address - Phone:715-254-4357
Mailing Address - Fax:715-343-8863
Practice Address - Street 1:1002 EUREKA STREET
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:WI
Practice Address - Zip Code:54971
Practice Address - Country:US
Practice Address - Phone:920-896-0440
Practice Address - Fax:920-896-0306
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COPERLEAF MANAGEMENT GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-07
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0015270310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility