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General NPI Number Information
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NPI Number | 1013915339
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Entity Type | Organization
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Legal Business Name | COUNTY OF WOOD
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Dates
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Enumeration Date | 07/11/2005
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Last Update Date | 09/09/2022
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Provider Practice Location Address
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Address Line | 1351 WISCONSIN RIVER DR
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City | PORT EDWARDS
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State | WI
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Zip | 54469-1041
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Country | US
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Telephone | 715-885-8300
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Fax | 715-885-8351
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Provider Business Mailing Address
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Address Line | 1351 WISCONSIN RIVER DR
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City | PORT EDWARDS
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State | WI
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Zip | 54469-1099
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Country | US
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Telephone | 715-885-8300
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Fax | 715-885-8351
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | KYLE THEILER
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Credential | NHA
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Telephone | 715-885-8324
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 2369
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License Number State | WI
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