MEDICARE: AMERICANWAY OF SAUK COUNTY LLC

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	3104A0625X	Assisted Living Facility (Mental Illness)		WI

General Provider Information

NPI Number	:	1215233127
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMERICANWAY OF SAUK COUNTY LLC

Provider Business Mailing Address
First Line	:	602 E ALBERT ST
Second Line	:	SUITE 3
City	:	PORTAGE
State	:	WI
Zip	:	53901-1463
Country	:	US
Telephone Number	:	608-566-1500
Fax Number	:	608-566-1501

Provider Business Practice Location Address
First Line	:	S7559 US HIGHWAY 12
Second Line	:
City	:	NORTH FREEDOM
State	:	WI
Zip	:	53951-9532
Country	:	US
Telephone Number	:	608-643-2232
Fax Number	:	608-643-2841

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	MRS. JANIS DEETS NOWAK
Credential	:	CPA,NHA
Telephone Number	:	608-566-1500

Provider Enumeration Date	:	02/10/2011
Last Update Date	:	02/10/2011

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