Basic Information
| Provider Information | |||||||||
| NPI: | 1568810422 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SCAL OF HOBART, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EMERALD RIDGE ASSISTED LIVING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3232 N BALLARD RD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549118804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9205743833 | ||||||||
| FaxNumber: | 9205743850 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 CENTENNIAL CENTRE BLVD | ||||||||
| Address2: | |||||||||
| City: | HOBART | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541558989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9205445041 | ||||||||
| FaxNumber: | 9205440857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2016 | ||||||||
| LastUpdateDate: | 06/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | TEGEN | ||||||||
| AuthorizedOfficialFirstName: | KATHERINE | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9203781913 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | WI | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.