Basic Information
| Provider Information | |||||||||
| NPI: | 1295178713 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRAVES ENTERPRISES INC D/B/A OREGON MANOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 354 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OREGON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535751426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088353535 | ||||||||
| FaxNumber: | 6088353890 | ||||||||
| Practice Location | |||||||||
| Address1: | 354 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OREGON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535751426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088353535 | ||||||||
| FaxNumber: | 6088353890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2013 | ||||||||
| LastUpdateDate: | 12/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | GRAVES | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6088353535 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LNHA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 20100100 | WI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 20100100 | 05 | WI | MEDICAID | 1114001666 | 01 | WI | NPI | OTHER |