Healthcare Provider Details

I. General information

NPI: 1649273350
Provider Name (Legal Business Name): MANAWA COMMUNITY NURSING CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 12/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E 4TH ST
MANAWA WI
54949
US

IV. Provider business mailing address

400 E 4TH ST
MANAWA WI
54949-9227
US

V. Phone/Fax

Practice location:
  • Phone: 920-596-2566
  • Fax: 920-596-2588
Mailing address:
  • Phone: 920-596-2566
  • Fax: 920-596-2588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2616
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier20105000
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer

VIII. Authorized Official

Name: MR. RUSSELL JOSEPH MATICEK SR.
Title or Position: OWNER
Credential:
Phone: 920-596-2566