=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558615815
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STATE OF WISCONSIN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2012
-----------------------------------------------------
Last Update Date | 01/06/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2175 E PARK AVE
-----------------------------------------------------
City | CHIPPEWA FALLS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54729-3511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-720-6775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2175 E PARK AVE
-----------------------------------------------------
City | CHIPPEWA FALLS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54729-3511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HOMES DIVISION ADMINISTRATOR
-----------------------------------------------------
Name | TAMMY L SERVATIUS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 715-258-4251
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 5039
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------