Provider Demographics
NPI:1912214966
Name:SUMAC RESIDENTIAL LLC
Entity Type:Organization
Organization Name:SUMAC RESIDENTIAL LLC
Other - Org Name:BLUE JAY ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-255-0466
Mailing Address - Street 1:723B BLUE JAY LN
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-7695
Mailing Address - Country:US
Mailing Address - Phone:715-255-0466
Mailing Address - Fax:
Practice Address - Street 1:723 B BLUE JAY LANE
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016
Practice Address - Country:US
Practice Address - Phone:715-255-0466
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities