Provider Demographics
NPI:1831486448
Name:GOLDEN HARBOR, LLC
Entity Type:Organization
Organization Name:GOLDEN HARBOR, LLC
Other - Org Name:GOLDEN HARBOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:TERESINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-940-6608
Mailing Address - Street 1:2448 S 102ND ST STE 305
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2141
Mailing Address - Country:US
Mailing Address - Phone:414-940-6608
Mailing Address - Fax:
Practice Address - Street 1:505 S WATER ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-4429
Practice Address - Country:US
Practice Address - Phone:262-470-5388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-03
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0013780OtherWISCONSIN DHS