Basic Information
Provider Information | |||||||||
NPI: | 1528246626 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ORION FREDERIC LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FREDERIC NURSING AND REHABILITATION COMMUNITY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5000 HAKES DR | ||||||||
Address2: | SUITE 600 | ||||||||
City: | NORTON SHORES | ||||||||
State: | MI | ||||||||
PostalCode: | 494415574 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2317996870 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 205 UNITED WAY | ||||||||
Address2: |   | ||||||||
City: | FREDERIC | ||||||||
State: | WI | ||||||||
PostalCode: | 548378938 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7153274297 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/31/2008 | ||||||||
LastUpdateDate: | 02/13/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LOCKHART | ||||||||
AuthorizedOfficialFirstName: | DENNIS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF ACCOUNTING OFFICER | ||||||||
AuthorizedOfficialTelephone: | 6144160600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 3086 | WI | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 800059155019 | 01 | WI | BCBS PROVIDER CODE | OTHER | 20200400 | 05 | WI |   | MEDICAID |