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General NPI Number Information
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NPI Number | 1265593503
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Entity Type | Organization
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Legal Business Name | WISCONSIN ILLINOIS SENIOR HOUSING, INC.
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Dates
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Enumeration Date | 12/12/2006
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Last Update Date | 07/18/2013
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Provider Practice Location Address
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Address Line | 313 STOUGHTON RD
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City | EDGERTON
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State | WI
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Zip | 53534-1132
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Country | US
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Telephone | 608-884-1330
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Fax | 608-884-1331
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Provider Business Mailing Address
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Address Line | 313 STOUGHTON RD
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City | EDGERTON
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State | WI
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Zip | 53534-1132
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Country | US
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Telephone | 608-884-1330
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Fax | 608-884-1331
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Authorized Official
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Title or Position | NURSING HOME ADMINISTRATOR
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Name | NICOLE HAYES
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Credential | NHA
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Telephone | 608-884-1617
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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 | 2235
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License Number State | WI
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