Provider Demographics
NPI:1609219195
Name:SHEBOYGAN SENIOR COMMUNITY
Entity Type:Organization
Organization Name:SHEBOYGAN SENIOR COMMUNITY
Other - Org Name:REHABCARE/KINDRED
Other - Org Type:Other Name
Authorized Official - Title/Position:DO
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-458-2137
Mailing Address - Street 1:5314 GROVE RD
Mailing Address - Street 2:
Mailing Address - City:REEDSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54230-9131
Mailing Address - Country:US
Mailing Address - Phone:920-228-0464
Mailing Address - Fax:920-459-0638
Practice Address - Street 1:5314 GROVE RD
Practice Address - Street 2:
Practice Address - City:REEDSVILLE
Practice Address - State:WI
Practice Address - Zip Code:54230-9131
Practice Address - Country:US
Practice Address - Phone:920-228-0464
Practice Address - Fax:920-459-0638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-15
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4640-27314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI526538Medicaid