Provider Demographics
NPI:1417466152
Name:NORTH OAK HEALTH CARE WISTERIA HAUS LLC
Entity Type:Organization
Organization Name:NORTH OAK HEALTH CARE WISTERIA HAUS LLC
Other - Org Name:WISTERIA HAUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:MASCHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-612-0750
Mailing Address - Street 1:1025 SHERMER RD
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-3730
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2741 45TH ST
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-1002
Practice Address - Country:US
Practice Address - Phone:847-612-0750
Practice Address - Fax:920-794-4057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-26
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X
WI0016823313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility