Basic Information
Provider Information | |||||||||
NPI: | 1417214651 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEYDE HEALTH SYSTEM PEPIN LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LAKEVIEW RESIDENCE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 345 FRENETTE DR | ||||||||
Address2: |   | ||||||||
City: | CHIPPEWA FALLS | ||||||||
State: | WI | ||||||||
PostalCode: | 547293372 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7157269094 | ||||||||
FaxNumber: | 7157231205 | ||||||||
Practice Location | |||||||||
Address1: | 1112 SECOND ST. | ||||||||
Address2: |   | ||||||||
City: | PEPIN | ||||||||
State: | WI | ||||||||
PostalCode: | 547599658 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7154424811 | ||||||||
FaxNumber: | 7154422904 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/12/2012 | ||||||||
LastUpdateDate: | 04/12/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | METTEN | ||||||||
AuthorizedOfficialFirstName: | MARTIN | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT/COO | ||||||||
AuthorizedOfficialTelephone: | 7157269094 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 13844 | WI | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
ID Information
ID | Type | State | Issuer | Description | 13844 | 01 | WI | WISCONSIN DEPARTMENT OF HEALTH SERVICES | OTHER |