Provider Demographics
NPI:1073510632
Name:ST JOSEPH RESIDENCE INC
Entity Type:Organization
Organization Name:ST JOSEPH RESIDENCE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:ORR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-982-5354
Mailing Address - Street 1:107 E BECKERT ROAD
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-2598
Mailing Address - Country:US
Mailing Address - Phone:920-982-5354
Mailing Address - Fax:920-982-5420
Practice Address - Street 1:107 E BECKERT ROAD
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-2598
Practice Address - Country:US
Practice Address - Phone:920-982-5354
Practice Address - Fax:920-982-5420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2040314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20132400Medicaid
WI20132400Medicaid