Provider Demographics
NPI:1770035982
Name:DYCORA TRANSITIONAL HEALTH - RIVERDALE, LLC
Entity Type:Organization
Organization Name:DYCORA TRANSITIONAL HEALTH - RIVERDALE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-786-3230
Mailing Address - Street 1:1000 N WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MUSCODA
Mailing Address - State:WI
Mailing Address - Zip Code:53573-9115
Mailing Address - Country:US
Mailing Address - Phone:608-739-3186
Mailing Address - Fax:
Practice Address - Street 1:1000 N WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MUSCODA
Practice Address - State:WI
Practice Address - Zip Code:53573-9115
Practice Address - Country:US
Practice Address - Phone:608-739-3186
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-04
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3188314000000X
314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI525321Medicare Oscar/Certification