Provider Demographics
NPI:1760522379
Name:EMERALD SHORES ASSISTED LIVING, LLC
Entity Type:Organization
Organization Name:EMERALD SHORES ASSISTED LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:TEGEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-378-5839
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:WI
Mailing Address - Zip Code:53088-0098
Mailing Address - Country:US
Mailing Address - Phone:920-388-2833
Mailing Address - Fax:920-388-2891
Practice Address - Street 1:1100 BAUMEISTER DR
Practice Address - Street 2:
Practice Address - City:KEWAUNEE
Practice Address - State:WI
Practice Address - Zip Code:54216-1646
Practice Address - Country:US
Practice Address - Phone:920-388-2833
Practice Address - Fax:920-388-2891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility