MEDICARE: CHRISTIAN HOME AND REHABILITATION CENTER, INC.

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	310400000X	Assisted Living Facility	0010292	WI
2	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility		WI
3	314000000X	Skilled Nursing Facility	0525	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	:	1457312209
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHRISTIAN HOME AND REHABILITATION CENTER, INC.

Provider Business Mailing Address
First Line	:	452 FOX LAKE RD
Second Line	:
City	:	WAUPUN
State	:	WI
Zip	:	53963-1761
Country	:	US
Telephone Number	:	920-324-9051
Fax Number	:	920-324-4724

Provider Business Practice Location Address
First Line	:	452 FOX LAKE RD
Second Line	:
City	:	WAUPUN
State	:	WI
Zip	:	53963-1761
Country	:	US
Telephone Number	:	920-324-9051
Fax Number	:	920-324-4724

Authorized Official
Title or Position	:	NURSING HOME ADMINISTRATOR
Name	:	MS. BARBARA L. WIRKUS
Credential	:	NHA
Telephone Number	:	920-324-9051

Provider Enumeration Date	:	03/31/2006
Last Update Date	:	01/07/2022

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