Provider Demographics
NPI:1861667248
Name:HCR MANOR CARE
Entity Type:Organization
Organization Name:HCR MANOR CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST ASSISTANT
Authorized Official - Prefix:MISS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WILLIQUETTE
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:920-922-7324
Mailing Address - Street 1:265 S NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-5334
Mailing Address - Country:US
Mailing Address - Phone:920-922-7342
Mailing Address - Fax:920-922-7335
Practice Address - Street 1:265 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-5334
Practice Address - Country:US
Practice Address - Phone:920-922-7342
Practice Address - Fax:920-922-7335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI172-019314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI172-019OtherWISCONSIN STATE LICENSE
WI40320900Medicaid