Provider Demographics
NPI:1952604688
Name:HERITAGE ASSISTED LIVING OF WATERTOWN, LLC
Entity Type:Organization
Organization Name:HERITAGE ASSISTED LIVING OF WATERTOWN, LLC
Other - Org Name:HERITAGE HOMES ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:REHM
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:920-206-9448
Mailing Address - Street 1:700 WELSH RD
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-4266
Mailing Address - Country:US
Mailing Address - Phone:920-206-9448
Mailing Address - Fax:920-567-2038
Practice Address - Street 1:700 WELSH RD
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-4266
Practice Address - Country:US
Practice Address - Phone:920-206-9448
Practice Address - Fax:920-567-2038
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE LUTHERAN HOME ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-20
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0013392310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0013392OtherCOMMUNITY-BASED RESIDENTIAL FACILITY LICENSE