Healthcare Provider Details

I. General information

NPI: 1649264623
Provider Name (Legal Business Name): WISCONSIN ILLINOIS SENIOR HOUSING INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 05/13/2020
Certification Date: 05/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 SUMMIT ST
WILD ROSE WI
54984-6804
US

IV. Provider business mailing address

425 SUMMIT ST
WILD ROSE WI
54984-6804
US

V. Phone/Fax

Practice location:
  • Phone: 920-622-4342
  • Fax: 920-622-3655
Mailing address:
  • Phone: 920-622-4342
  • Fax: 920-622-3655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2606
License Number StateWI

VIII. Authorized Official

Name: MRS. STEPHANIE L. SHERMAN
Title or Position: MEDICARE PROGRAM MONITOR
Credential:
Phone: 303-980-0611