Provider Demographics
NPI:1942488044
Name:CONGREGATIONAL HOME INC
Entity type:Organization
Organization Name:CONGREGATIONAL HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT COO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:T
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-781-0550
Mailing Address - Street 1:3150 LILLY ROAD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-7623
Mailing Address - Country:US
Mailing Address - Phone:262-781-0550
Mailing Address - Fax:262-781-0559
Practice Address - Street 1:3150 LILLY ROAD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-7623
Practice Address - Country:US
Practice Address - Phone:262-781-0550
Practice Address - Fax:262-781-0559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2471314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility