Provider Demographics
NPI:1972135838
Name:HEATHERLYN ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:HEATHERLYN ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JHIENELLE
Authorized Official - Middle Name:TALETHIA
Authorized Official - Last Name:KISTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-397-1610
Mailing Address - Street 1:327 E CLAY ST UNIT 19
Mailing Address - Street 2:
Mailing Address - City:WHITEWATER
Mailing Address - State:WI
Mailing Address - Zip Code:53190-2077
Mailing Address - Country:US
Mailing Address - Phone:920-397-1610
Mailing Address - Fax:
Practice Address - Street 1:811 ROBERT ST
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1140
Practice Address - Country:US
Practice Address - Phone:920-397-1610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-09
Last Update Date:2020-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility