Organization
COUNTRY GROVE HOME LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. SCOTT A PEAK (OWNER)
(608) 547-2755
Entity
Organization
Contact information
Practice address
N11151 17TH AVE, NECEDAH, WI 54646-7619
(608) 565-2735
Mailing address
N10414 18TH AVE, NECEDAH, WI 54646-7934
(608) 547-2752
Taxonomy
Speciality
Code
Description
License number
State
3104A0625X
Assisted Living Facility (Mental Illness)
Primary
0011011
WI
Other
Enumeration date
04/12/2010
Last updated
04/12/2010
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