Basic Information
| Provider Information | |||||||||
| NPI: | 1154320802 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BARRON HEALTHCARE CENTER INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BARRON RIVERSIDE MANOR | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 E BIRCH AVE | ||||||||
| Address2: | |||||||||
| City: | BARRON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548129130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7155375643 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 660 E BIRCH AVE | ||||||||
| Address2: | |||||||||
| City: | BARRON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548129130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7155375643 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2005 | ||||||||
| LastUpdateDate: | 10/29/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THAYER | ||||||||
| AuthorizedOfficialFirstName: | GRANT | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7158371222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| 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 | 20167400 | 05 | WI | MEDICAID |