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General NPI Number Information
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NPI Number | 1235225616
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Entity Type | Organization
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Legal Business Name | STATE OF WISCONSIN
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Dates
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Enumeration Date | 10/05/2006
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Last Update Date | 04/30/2025
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Provider Practice Location Address
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Address Line | 2820 EAST PARK AVENUE
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City | CHIPPEWA FALLS
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State | WI
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Zip | 54729-0340
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Country | US
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Telephone | 715-723-7957
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Fax |
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Provider Business Mailing Address
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Address Line | 2820 EAST PARK AVENUE
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City | CHIPPEWA FALLS
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State | WI
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Zip | 54729-0340
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | CRAIG KOEHLER
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Credential |
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Telephone | 715-723-5542
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 2753
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License Number State | WI
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