Healthcare Provider Details

I. General information

NPI: 1558615815
Provider Name (Legal Business Name): STATE OF WISCONSIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2012
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2175 E PARK AVE
CHIPPEWA FALLS WI
54729-3511
US

IV. Provider business mailing address

2175 E PARK AVE
CHIPPEWA FALLS WI
54729-3511
US

V. Phone/Fax

Practice location:
  • Phone: 715-720-6775
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number5039
License Number StateWI

VIII. Authorized Official

Name: TAMMY L SERVATIUS
Title or Position: HOMES DIVISION ADMINISTRATOR
Credential:
Phone: 715-258-4251