Basic Information
| Provider Information | |||||||||
| NPI: | 1891029112 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH CENTRAL HEALTH CARE MOUNTVIEW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1352 N 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | WEST BEND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530901814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623918666 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2400 MARSHALL ST | ||||||||
| Address2: | |||||||||
| City: | WAUSAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544036738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158484300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2009 | ||||||||
| LastUpdateDate: | 09/21/2009 | ||||||||
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| AuthorizedOfficialLastName: | SHUBERT | ||||||||
| AuthorizedOfficialFirstName: | STACY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OTR | ||||||||
| AuthorizedOfficialTelephone: | 7155701717 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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| AuthorizedOfficialCredential: | OTR | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 4721027 | WI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.