Healthcare Provider Details

I. General information

NPI: 1992911796
Provider Name (Legal Business Name): WOODLAND VILLAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 MANOR DR
SURING WI
54174-9182
US

IV. Provider business mailing address

1111 S RIVER ST
SHAWANO WI
54166-3229
US

V. Phone/Fax

Practice location:
  • Phone: 902-842-2191
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number1530-027
License Number StateWI

VIII. Authorized Official

Name: MICHELLE ANKER
Title or Position: COTA
Credential:
Phone: 920-842-2191