Basic Information
| Provider Information | |||||||||
| NPI: | 1003000514 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SENIOR MANAGEMENT INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BARRON CARE & REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 660 E BIRCH AVE | ||||||||
| Address2: | |||||||||
| City: | BARRON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548129130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7155375643 | ||||||||
| FaxNumber: | 7155371222 | ||||||||
| Practice Location | |||||||||
| Address1: | 660 E BIRCH AVE | ||||||||
| Address2: | |||||||||
| City: | BARRON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548129130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7155375643 | ||||||||
| FaxNumber: | 7155371222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2007 | ||||||||
| LastUpdateDate: | 01/10/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THAYER | ||||||||
| AuthorizedOfficialFirstName: | GRANT | ||||||||
| AuthorizedOfficialMiddleName: | DONALD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5076572231 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SENIOR MANAGEMENT INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | NHA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 3038 | WI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 20198800 | 05 | WI | MEDICAID |