MEDICARE: STATE OF WISCONSIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	315P00000X	Intellectual Disabilities Intermediate Care Facility	2763	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043326747
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF WISCONSIN

Provider Business Mailing Address
First Line	:	21425 SPRING ST
Second Line	:
City	:	UNION GROVE
State	:	WI
Zip	:	53182-9707
Country	:	US
Telephone Number	:	262-878-2411
Fax Number	:	262-878-2922

Provider Business Practice Location Address
First Line	:	21425 SPRING ST
Second Line	:
City	:	UNION GROVE
State	:	WI
Zip	:	53182-9707
Country	:	US
Telephone Number	:	262-878-2411
Fax Number	:	262-878-2922

Authorized Official
Title or Position	:	NURSING HOME ADMINISTRATOR
Name	:	MR. JAMES E HUTCHISON
Credential	:
Telephone Number	:	262-878-2411

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	02/14/2008

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Directions to “STATE OF WISCONSIN ” Practice Location

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