Provider Demographics
NPI:1043326747
Name:STATE OF WISCONSIN
Entity Type:Organization
Organization Name:STATE OF WISCONSIN
Other - Org Name:SOUTHERN WISCONSIN CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NURSING HOME ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:HUTCHISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-878-2411
Mailing Address - Street 1:21425 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:UNION GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53182-9707
Mailing Address - Country:US
Mailing Address - Phone:262-878-2411
Mailing Address - Fax:262-878-2922
Practice Address - Street 1:21425 SPRING ST
Practice Address - Street 2:
Practice Address - City:UNION GROVE
Practice Address - State:WI
Practice Address - Zip Code:53182-9707
Practice Address - Country:US
Practice Address - Phone:262-878-2411
Practice Address - Fax:262-878-2922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2763315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21050000Medicaid