1720088495 NPI number — COUNTY OF SHAWANO

Table of content: (NPI 1720088495)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720088495 NPI number — COUNTY OF SHAWANO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTY OF SHAWANO
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MAPLE LANE HEALTH CARE CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720088495
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
N4231 STATE HIGHWAY 22
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHAWANO
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54166-6130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-526-3158
Provider Business Mailing Address Fax Number:
715-526-6823

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
N4231 STATE HIGHWAY 22
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHAWANO
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54166-6130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-526-3158
Provider Business Practice Location Address Fax Number:
715-526-6823
Provider Enumeration Date:
07/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KESSEN
Authorized Official First Name:
DEBBRA
Authorized Official Middle Name:
R
Authorized Official Title or Position:
ACCOUNTANT/CONTROLLER
Authorized Official Telephone Number:
715-526-3158

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X , with the licence number:  2994 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 21051100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com