Basic Information
| Provider Information | |||||||||
| NPI: | 1356374367 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HP SUPERIOR INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 925 N POINT PKWY | ||||||||
| Address2: | SUITE 440 | ||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300055210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706190866 | ||||||||
| FaxNumber: | 7708702892 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 NEW YORK AVE | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548802008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153945591 | ||||||||
| FaxNumber: | 7153945098 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MITTLEIDER | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7706190866 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 2578 | WI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 20192500 | 05 | WI | MEDICAID |