MEDICARE: FOUR WINDS MANOR, 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	314000000X	Skilled Nursing Facility	1002	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	:	1902895592
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOUR WINDS MANOR, INC.

Provider Business Mailing Address
First Line	:	303 S JEFFERSON ST
Second Line	:
City	:	VERONA
State	:	WI
Zip	:	53593-1415
Country	:	US
Telephone Number	:	608-845-6465
Fax Number	:	608-848-8315

Provider Business Practice Location Address
First Line	:	303 S JEFFERSON ST
Second Line	:
City	:	VERONA
State	:	WI
Zip	:	53593-1415
Country	:	US
Telephone Number	:	608-845-6465
Fax Number	:	608-848-8315

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. JUANITA ROSE RETRUM
Credential	:
Telephone Number	:	608-845-6465

Provider Enumeration Date	:	10/17/2005
Last Update Date	:	08/22/2020

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Directions to “FOUR WINDS MANOR, INC. ” Practice Location

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