Provider Demographics
NPI:1790169944
Name:KENOSHA SENIOR LIVING, INC.
Entity Type:Organization
Organization Name:KENOSHA SENIOR LIVING, INC.
Other - Org Name:KENOSHA SENIOR LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-401-1369
Mailing Address - Street 1:3109 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1673
Mailing Address - Country:US
Mailing Address - Phone:262-656-1795
Mailing Address - Fax:262-656-1875
Practice Address - Street 1:3109 30TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1673
Practice Address - Country:US
Practice Address - Phone:262-656-1795
Practice Address - Fax:262-656-1875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility