Basic Information
| Provider Information | |||||||||
| NPI: | 1427266550 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUNNY RIDGE HEALTH AND REHAB | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2644 N 71ST ST | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532131349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6127470119 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3014 ERIE AVE | ||||||||
| Address2: | |||||||||
| City: | SHEBOYGAN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530813658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204593028 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KASTENHOLZ | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL DIRECTOR OF THERAPY | ||||||||
| AuthorizedOfficialTelephone: | 6127470119 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OTR | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 3086-026 | WI | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
No ID Information.