Basic Information
| Provider Information | |||||||||
| NPI: | 1790141158 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 1840 PRIDDY STREET OPERATING COMPANY, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ATRIUM POST ACUTE CARE OF BLOOMER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1726 N BALLARD RD | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549112444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209919072 | ||||||||
| FaxNumber: | 9207494022 | ||||||||
| Practice Location | |||||||||
| Address1: | 1840 PRIDDY ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547241546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7155682503 | ||||||||
| FaxNumber: | 7155682518 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2016 | ||||||||
| LastUpdateDate: | 04/05/2016 | ||||||||
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| AuthorizedOfficialLastName: | BRESLIN | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9733398892 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 2807 | WI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1790141158 | 05 | WI | MEDICAID |