Provider Demographics
NPI:1477627677
Name:WAUSA LEISURE LIVING, LLC
Entity Type:Organization
Organization Name:WAUSA LEISURE LIVING, LLC
Other - Org Name:COUNTRYSIDE VILLA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOLCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-586-2890
Mailing Address - Street 1:803 S VIVIAN ST
Mailing Address - Street 2:
Mailing Address - City:WAUSA
Mailing Address - State:NE
Mailing Address - Zip Code:68786-2046
Mailing Address - Country:US
Mailing Address - Phone:402-586-2890
Mailing Address - Fax:402-586-2945
Practice Address - Street 1:803 S VIVIAN ST
Practice Address - Street 2:
Practice Address - City:WAUSA
Practice Address - State:NE
Practice Address - Zip Code:68786-2046
Practice Address - Country:US
Practice Address - Phone:402-586-2890
Practice Address - Fax:402-586-2945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEALF232310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility