Basic Information
| Provider Information | |||||||||
| NPI: | 1568914729 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NSH DORCHESTER LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | STURGEON BAY HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5150 N PORT WASHINGTON RD | ||||||||
| Address2: | SUITE 260 | ||||||||
| City: | GLENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532175474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149625250 | ||||||||
| FaxNumber: | 4149625251 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 N 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | STURGEON BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542351708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207436274 | ||||||||
| FaxNumber: | 9207435604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2016 | ||||||||
| LastUpdateDate: | 12/29/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOEHN | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | CHARLES | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 4149625250 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NSHG WISCONSIN LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 2681 | WI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.