Provider Demographics
NPI:1467841973
Name:CROGHAN ADULT CARE FACILITY LLC
Entity Type:Organization
Organization Name:CROGHAN ADULT CARE FACILITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:E
Authorized Official - Last Name:KEPLER
Authorized Official - Suffix:
Authorized Official - Credentials:MS/P
Authorized Official - Phone:608-475-0006
Mailing Address - Street 1:1062 OAK FOREST DR
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-3489
Mailing Address - Country:US
Mailing Address - Phone:608-519-2306
Mailing Address - Fax:608-519-2307
Practice Address - Street 1:9837 MAIN STREET
Practice Address - Street 2:
Practice Address - City:CROGHAN
Practice Address - State:NY
Practice Address - Zip Code:13327
Practice Address - Country:US
Practice Address - Phone:315-408-8973
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No385H00000XRespite Care FacilityRespite Care