Eric Gerald Phelps
Individual provider Active NPI Adult Care Home Facility · Cornell, WI
NPI 1003583238 · NPPES record last updated Aug 25, 2021
Key facts
- NPI
- 1003583238
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Adult Care Home Facility 311ZA0620X
- Practice address
- 104 N 11TH St
Cornell, WI 54732-8106 - Phone
- (715) 202-3586
- NPI assigned
- Aug 25, 2021
- Sex
- Male
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Adult Care Home Facility | 311ZA0620X | Yes |
Addresses
Primary practice location
104 N 11TH St
Cornell, WI 54732-8106
Mailing address
104 N 11TH St
Cornell, WI 54732-8106
Phone (715) 202-3586
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 100178091 | Medicaid | WI |
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All providers in Cornell, WI · Adult Care Home Facility in Wisconsin
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 25, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.