Provider Demographics
NPI:1538490438
Name:CAROLINA MANOR ASSISTED LIVING OF APPLETON, LLC
Entity Type:Organization
Organization Name:CAROLINA MANOR ASSISTED LIVING OF APPLETON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:R
Authorized Official - Last Name:TEGEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-378-5839
Mailing Address - Street 1:3201 W 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-1131
Mailing Address - Country:US
Mailing Address - Phone:920-738-0118
Mailing Address - Fax:920-738-0641
Practice Address - Street 1:W3124 VAN ROY RD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-3982
Practice Address - Country:US
Practice Address - Phone:920-574-3833
Practice Address - Fax:920-574-3850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-18
Last Update Date:2010-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility