Provider Demographics
NPI:1093701088
Name:AUGUSTA AREA HOME, INC
Entity Type:Organization
Organization Name:AUGUSTA AREA HOME, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-286-2266
Mailing Address - Street 1:215 E BROWN ST
Mailing Address - Street 2:P.O.BOX 387
Mailing Address - City:AUGUSTA
Mailing Address - State:WI
Mailing Address - Zip Code:54722-9346
Mailing Address - Country:US
Mailing Address - Phone:715-286-2266
Mailing Address - Fax:715-286-2653
Practice Address - Street 1:215 E BROWN ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:WI
Practice Address - Zip Code:54722-9346
Practice Address - Country:US
Practice Address - Phone:715-286-2266
Practice Address - Fax:715-286-2653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2083314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20010300Medicaid
WI20010300Medicaid