Organization
HCR MANOR CARE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MISS ANGELA LEE WILLIQUETTE PTA (PHYSICAL THERAPIST ASSISTANT)
(920) 922-7324
Entity
Organization
Contact information
Practice address
265 S NATIONAL AVE, FOND DU LAC, WI 54935-5334
(920) 922-7342
(920) 922-7335
Mailing address
265 S NATIONAL AVE, FOND DU LAC, WI 54935-5334
(920) 922-7342
(920) 922-7335
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
172-019
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
172-019
WISCONSIN STATE LICENSE
WI
05
—
40320900
—
WI
Enumeration date
04/25/2008
Last updated
04/25/2008
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