Basic Information
| Provider Information | |||||||||
| NPI: | 1386637544 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILLIAMS BAY CARE CENTER LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ATRIUM POST ACUTE CARE OF WILLIAMS BAY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1726 N BALLARD RD | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549112444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209919072 | ||||||||
| FaxNumber: | 9207494021 | ||||||||
| Practice Location | |||||||||
| Address1: | 146 CLOVER ST | ||||||||
| Address2: | |||||||||
| City: | WILLIAMS BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531919779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622456400 | ||||||||
| FaxNumber: | 2622459271 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 05/27/2015 | ||||||||
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| AuthorizedOfficialLastName: | PARKINS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9203649754 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 3220 | WI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 20188300 | 05 | WI | MEDICAID |