Provider Demographics
NPI:1588089114
Name:TRADITIONS OF FREDERIC
Entity type:Organization
Organization Name:TRADITIONS OF FREDERIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:715-497-6101
Mailing Address - Street 1:107 OAK ST E
Mailing Address - Street 2:
Mailing Address - City:FREDERIC
Mailing Address - State:WI
Mailing Address - Zip Code:54837-9500
Mailing Address - Country:US
Mailing Address - Phone:715-327-4889
Mailing Address - Fax:715-327-4890
Practice Address - Street 1:107 OAK ST E
Practice Address - Street 2:
Practice Address - City:FREDERIC
Practice Address - State:WI
Practice Address - Zip Code:54837-9500
Practice Address - Country:US
Practice Address - Phone:715-327-4888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-18
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0013890310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility