Provider Demographics
NPI:1265589303
Name:THEDA CARE PEABODY MANOR
Entity type:Organization
Organization Name:THEDA CARE PEABODY MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:TONI
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:RADISH
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:920-225-7764
Mailing Address - Street 1:W7409 REDHAWK DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-9153
Mailing Address - Country:US
Mailing Address - Phone:920-757-0190
Mailing Address - Fax:
Practice Address - Street 1:2600 S HERITAGE WOODS DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1408
Practice Address - Country:US
Practice Address - Phone:920-225-7764
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9771-24314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility