Provider Demographics
NPI:1124006739
Name:ODD FELLOW REBEKAH HOME ASSOCIATION INC
Entity type:Organization
Organization Name:ODD FELLOW REBEKAH HOME ASSOCIATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:EVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:CEO, NHA, RN
Authorized Official - Phone:920-593-1640
Mailing Address - Street 1:1207 SOUTH JACKSON STREET
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301
Mailing Address - Country:US
Mailing Address - Phone:920-593-1640
Mailing Address - Fax:920-435-5031
Practice Address - Street 1:1207 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3037
Practice Address - Country:US
Practice Address - Phone:920-593-1640
Practice Address - Fax:920-435-5031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-04
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2544314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20151600Medicaid
WI525559Medicare Oscar/Certification