Basic Information
| Provider Information | |||||||||
| NPI: | 1972045698 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NSH RANDOLPH LLC | ||||||||
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| OtherOrganizationName: | CONTINENTAL MANOR OF RANDOLPH HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5150 N PORT WASHINGTON RD | ||||||||
| Address2: | SUITE 260 | ||||||||
| City: | GLENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532175474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149625250 | ||||||||
| FaxNumber: | 4149625251 | ||||||||
| Practice Location | |||||||||
| Address1: | 502 S HIGH ST | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539561499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203263171 | ||||||||
| FaxNumber: | 9203263239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2016 | ||||||||
| LastUpdateDate: | 12/30/2016 | ||||||||
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| AuthorizedOfficialLastName: | HOEHN | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | CHARLES | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 6366988600 | ||||||||
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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 |
No ID Information.