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	314000000X	Skilled Nursing Facility	5039	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	:	1558615815
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF WISCONSIN

Provider Business Mailing Address
First Line	:	2175 E PARK AVE
Second Line	:
City	:	CHIPPEWA FALLS
State	:	WI
Zip	:	54729-3511
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2175 E PARK AVE
Second Line	:
City	:	CHIPPEWA FALLS
State	:	WI
Zip	:	54729-3511
Country	:	US
Telephone Number	:	715-720-6775
Fax Number	:

Authorized Official
Title or Position	:	HOMES DIVISION ADMINISTRATOR
Name	:	TAMMY L SERVATIUS
Credential	:
Telephone Number	:	715-258-4251

Provider Enumeration Date	:	11/07/2012
Last Update Date	:	01/06/2026

Similar Medicare Providers

1447337068 — STEPHANIE GANSCHOW PHARMD
Practice Location Address:

2500 E 52ND ST N , CIGNA MEDICARE SERVICES
SIOUX FALLS, SD
57104-7106

Practice Phone: 605-373-0100
Practice Fax:

1801320205 — SONDRA L KNAPCIK
Practice Location Address:

2175 E PARK AVE
CHIPPEWA FALLS, WI
54729-3511

Practice Phone: 715-720-6775
Practice Fax:

1922840362 — ANNASTASIA VALDEZ
Practice Location Address:

3511 1ST AVE N STE 1
GREAT FALLS, MT
59401-3527

Practice Phone: 406-788-3909
Practice Fax:

1316927288 — BRUCE EDWARD JOHNSON CHIROPRACTOR
Practice Location Address:

4627 W HOMEFIELD DR
SIOUX FALLS, SD
57106-3511

Practice Phone: 605-336-2010
Practice Fax: 605-336-0249

1831163047 — MR. STEPHEN ANTHONY MCCLARY PA-C
Practice Location Address:

3511 1ST AVE N
GREAT FALLS, MT
59401-3527

Practice Phone: 406-727-5778
Practice Fax: 406-761-7117

1770593964 — DR. RYAN M. JOHNSON D.C
Practice Location Address:

4627 W HOMEFIELD DR
SIOUX FALLS, SD
57106-3511

Practice Phone: 605-336-2010
Practice Fax: 605-336-0249

Directions to “STATE OF WISCONSIN ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.