Provider Demographics
NPI:1780030064
Name:MGM-EASTVIEW
Entity Type:Organization
Organization Name:MGM-EASTVIEW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REHAB TECH
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-623-2356
Mailing Address - Street 1:PO BOX 219
Mailing Address - Street 2:340A MAIN STREET
Mailing Address - City:BIRNAMWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:54414-0219
Mailing Address - Country:US
Mailing Address - Phone:920-606-2811
Mailing Address - Fax:
Practice Address - Street 1:729 PARK ST
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2745
Practice Address - Country:US
Practice Address - Phone:715-623-2356
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-05
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5265314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility