Provider Demographics
NPI:1659358323
Name:FOND DU LAC COUNTY
Entity Type:Organization
Organization Name:FOND DU LAC COUNTY
Other - Org Name:HARBOR HAVEN HEALTH & REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:RADMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-929-3309
Mailing Address - Street 1:459 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4505
Mailing Address - Country:US
Mailing Address - Phone:920-929-3543
Mailing Address - Fax:920-929-7509
Practice Address - Street 1:459 E 1ST ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4505
Practice Address - Country:US
Practice Address - Phone:920-929-3543
Practice Address - Fax:920-929-7509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-23
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2437314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20130800Medicaid
52 5534Medicare ID - Type Unspecified