Basic Information
| Provider Information | |||||||||
| NPI: | 1861796492 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY HERITAGE NURSING & REHABILITATION CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1311 TYLER ST | ||||||||
| Address2: | |||||||||
| City: | BLACK RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546151564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152844396 | ||||||||
| FaxNumber: | 7152847786 | ||||||||
| Practice Location | |||||||||
| Address1: | 1311 TYLER ST | ||||||||
| Address2: | |||||||||
| City: | BLACK RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546151564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152844396 | ||||||||
| FaxNumber: | 7152847786 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2010 | ||||||||
| LastUpdateDate: | 07/12/2011 | ||||||||
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| AuthorizedOfficialLastName: | ORLINSKY | ||||||||
| AuthorizedOfficialFirstName: | MOSHE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3145887518 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 3211 | WI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 20183900 | 05 | WI | MEDICAID | 100012961 | 05 | WI | MEDICAID |