Healthcare Provider Details

I. General information

NPI: 1750305520
Provider Name (Legal Business Name): WASHINGTON COUNTY WISCONSIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 12/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 PLEASANT VALLEY RD
WEST BEND WI
53095-9274
US

IV. Provider business mailing address

531 E WASHINGTON ST
WEST BEND WI
53095-2531
US

V. Phone/Fax

Practice location:
  • Phone: 262-707-6800
  • Fax: 262-707-6801
Mailing address:
  • Phone: 262-335-4500
  • Fax: 262-335-4699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number3192
License Number StateWI

VIII. Authorized Official

Name: MR. EDWARD EUGENE SOMERS
Title or Position: ADMINISTRATOR
Credential: NHA
Phone: 262-335-4500