Basic Information
| Provider Information | |||||||||
| NPI: | 1164005732 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GLENDALE CARE AND REHAB CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6263 N GREEN BAY AVE | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532093823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143510543 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6263 N GREEN BAY AVE | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532093823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143510543 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2021 | ||||||||
| LastUpdateDate: | 09/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | STEIN | ||||||||
| AuthorizedOfficialFirstName: | SHALOM | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED SIGNER | ||||||||
| AuthorizedOfficialTelephone: | 7323130880 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.