Basic Information
| Provider Information | |||||||||
| NPI: | 1083892186 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ORION TOMAH LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TOMAH HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 HAKES DR | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | NORTON SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494415574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317996870 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1505 BUTTS AVE | ||||||||
| Address2: | |||||||||
| City: | TOMAH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546602405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083723241 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2008 | ||||||||
| LastUpdateDate: | 02/13/2014 | ||||||||
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| AuthorizedOfficialLastName: | LOCKHART | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF ACCOUNTING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6144160600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 2825 | WI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 621810991030 | 01 | WI | BCBS PROVIDER CODE | OTHER | 20200300 | 05 | WI | MEDICAID |