Provider Demographics
NPI:1407943681
Name:THI OF WISCONSIN AT HARTFORD, LLC
Entity Type:Organization
Organization Name:THI OF WISCONSIN AT HARTFORD, LLC
Other - Org Name:THE PAVILION AT GLACIER VALLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:OHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-297-6300
Mailing Address - Street 1:1900 AMERICAN EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:SLINGER
Mailing Address - State:WI
Mailing Address - Zip Code:53086-9043
Mailing Address - Country:US
Mailing Address - Phone:262-297-6300
Mailing Address - Fax:
Practice Address - Street 1:1900 AMERICAN EAGLE DR
Practice Address - Street 2:
Practice Address - City:SLINGER
Practice Address - State:WI
Practice Address - Zip Code:53086-9043
Practice Address - Country:US
Practice Address - Phone:262-297-6300
Practice Address - Fax:262-297-6301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20191500Medicaid
525461Medicare Oscar/Certification