Provider Demographics
NPI:1760650287
Name:PEABODY MANOR
Entity type:Organization
Organization Name:PEABODY MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REHAD DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JEAN-PIERRE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:920-225-7785
Mailing Address - Street 1:817 N APPLETON ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-4503
Mailing Address - Country:US
Mailing Address - Phone:
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?:Yes
Parent Organization LBN:THEDACARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI538-019314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility