Provider Demographics
NPI:1427387661
Name:PROVINCE TERRACE VILLAS LONG CT. LLC
Entity Type:Organization
Organization Name:PROVINCE TERRACE VILLAS LONG CT. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:REEVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-257-2573
Mailing Address - Street 1:5216 LONG CT
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-9111
Mailing Address - Country:US
Mailing Address - Phone:920-257-2573
Mailing Address - Fax:920-882-0295
Practice Address - Street 1:5216 LONG COURT
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914
Practice Address - Country:US
Practice Address - Phone:920-257-2573
Practice Address - Fax:920-882-0295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-17
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0012777310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility