Healthcare Provider Details

I. General information

NPI: 1902895592
Provider Name (Legal Business Name): FOUR WINDS MANOR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S JEFFERSON ST
VERONA WI
53593-1415
US

IV. Provider business mailing address

303 S JEFFERSON ST
VERONA WI
53593-1415
US

V. Phone/Fax

Practice location:
  • Phone: 608-845-6465
  • Fax: 608-848-8315
Mailing address:
  • Phone: 608-845-6465
  • Fax: 608-848-8315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1002
License Number StateWI

VIII. Authorized Official

Name: MRS. JUANITA ROSE RETRUM
Title or Position: OFFICE MANAGER
Credential:
Phone: 608-845-6465