Provider Demographics
NPI:1427874825
Name:PALMER ROAD LLC
Entity type:Organization
Organization Name:PALMER ROAD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:KLUG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-903-2624
Mailing Address - Street 1:PO BOX 224
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-0224
Mailing Address - Country:US
Mailing Address - Phone:262-903-2624
Mailing Address - Fax:
Practice Address - Street 1:945 LAKE GENEVA BLVD
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-2443
Practice Address - Country:US
Practice Address - Phone:262-903-2624
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility