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General NPI Number Information
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NPI Number | 1366932436
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Entity Type | Organization
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Legal Business Name | WISCONSIN INDEPENDENT LIVING, INC.
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Dates
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Enumeration Date | 05/15/2018
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Last Update Date | 05/15/2018
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Provider Practice Location Address
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Address Line | 757 PLEASANT LN
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City | MENASHA
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State | WI
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Zip | 54952-2439
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Country | US
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Telephone | 920-215-3485
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Fax |
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Provider Business Mailing Address
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Address Line | 1610 W WISCONSIN AVE
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City | APPLETON
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State | WI
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Zip | 54914-3273
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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 | PRESIDENT
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Name | CORINNA LUNDQUIST
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Credential |
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Telephone | 920-252-1054
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State | WI
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