Basic Information
| Provider Information | |||||||||
| NPI: | 1801006580 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREENFIELD REHAB AGENCY UNC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | N5742 CTY C | ||||||||
| Address2: | |||||||||
| City: | CASCO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208372370 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1308 LINCOLN ST | ||||||||
| Address2: | |||||||||
| City: | KEWAUNEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542161606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203884111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAVERKORN | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | JO | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 9203884111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PTA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 223019 | WI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.