Provider Demographics
NPI:1912991092
Name:NAZARETH FACILITIES, LLC
Entity Type:Organization
Organization Name:NAZARETH FACILITIES, LLC
Other - Org Name:NAZARETH HEALTH AND REHABILITATION CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRISCOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-537-5700
Mailing Address - Street 1:12900 WHITEWATER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:HOPKINS
Mailing Address - State:MN
Mailing Address - Zip Code:55343-9407
Mailing Address - Country:US
Mailing Address - Phone:763-537-5700
Mailing Address - Fax:
Practice Address - Street 1:814 JACKSON ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-1520
Practice Address - Country:US
Practice Address - Phone:608-873-6448
Practice Address - Fax:608-873-0829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-06
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1159314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20197700Medicaid
WI525681Medicare ID - Type Unspecified