Healthcare Provider Details

I. General information

NPI: 1235225616
Provider Name (Legal Business Name): STATE OF WISCONSIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 04/30/2025
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 EAST PARK AVENUE
CHIPPEWA FALLS WI
54729-0340
US

IV. Provider business mailing address

2820 EAST PARK AVENUE
CHIPPEWA FALLS WI
54729-0340
US

V. Phone/Fax

Practice location:
  • Phone: 715-723-7957
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number2753
License Number StateWI

VIII. Authorized Official

Name: CRAIG KOEHLER
Title or Position: DIRECTOR
Credential:
Phone: 715-723-5542