Basic Information
| Provider Information | |||||||||
| NPI: | 1902382328 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CCC OF EAST GREEN BAY | ||||||||
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| OtherOrganizationName: | CROSSROADS CARE CENTER OF EAST GREEN BAY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8150 CENTRAL PARK AVE | ||||||||
| Address2: | |||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600762974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479834860 | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 S WEBSTER AVE | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543013503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204323213 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2018 | ||||||||
| LastUpdateDate: | 03/29/2019 | ||||||||
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| AuthorizedOfficialLastName: | MERZEL | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8479834860 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 000000 | 05 | WI | MEDICAID |