Basic Information
| Provider Information | |||||||||
| NPI: | 1366437006 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEPIN OPERATOR, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | PEPIN HEALTH AND REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1110 SECOND STREET | ||||||||
| Address2: | |||||||||
| City: | PEPIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547599658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154424811 | ||||||||
| FaxNumber: | 7154422904 | ||||||||
| Practice Location | |||||||||
| Address1: | 1110 2ND ST | ||||||||
| Address2: | |||||||||
| City: | PEPIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547599658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154424811 | ||||||||
| FaxNumber: | 7154422904 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2005 | ||||||||
| LastUpdateDate: | 07/29/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LINDEMEN | ||||||||
| AuthorizedOfficialFirstName: | STUART | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO & PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8132801333 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 3165 | WI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 20189800 | 05 | WI | MEDICAID |