Healthcare Provider Details

I. General information

NPI: 1124028519
Provider Name (Legal Business Name): COUNTY OF SHAWANO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 09/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N4231 STATE HIGHWAY 22
SHAWANO WI
54166-6130
US

IV. Provider business mailing address

N4231 STATE HIGHWAY 22
SHAWANO WI
54166-6130
US

V. Phone/Fax

Practice location:
  • Phone: 715-526-3158
  • Fax: 715-526-6823
Mailing address:
  • Phone: 715-526-3158
  • Fax: 715-526-6823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2579
License Number StateWI

VIII. Authorized Official

Name: MRS. DEBBRA R KESSEN
Title or Position: ACCOUNTANT/CONTROLLER
Credential:
Phone: 715-526-3158