Provider Demographics
NPI:1053949404
Name:A GREAT PLACE TO STAY LLC
Entity type:Organization
Organization Name:A GREAT PLACE TO STAY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-204-2722
Mailing Address - Street 1:716 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-2204
Mailing Address - Country:US
Mailing Address - Phone:920-204-2722
Mailing Address - Fax:
Practice Address - Street 1:35580 N KNOWLES RD
Practice Address - Street 2:
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046-9026
Practice Address - Country:US
Practice Address - Phone:920-204-2722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-31
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities