Provider Demographics
NPI:1134123573
Name:VILLA MARINA HEALTH AND REHABILITATION CENTER INC
Entity Type:Organization
Organization Name:VILLA MARINA HEALTH AND REHABILITATION CENTER INC
Other - Org Name:CHAFFEY NURSING HOME
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:KUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-561-3200
Mailing Address - Street 1:300 VILLA DRIVE
Mailing Address - Street 2:
Mailing Address - City:HURLEY
Mailing Address - State:WI
Mailing Address - Zip Code:54534-1523
Mailing Address - Country:US
Mailing Address - Phone:715-561-3200
Mailing Address - Fax:715-561-5556
Practice Address - Street 1:35 NORTH 28TH STREET
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5557
Practice Address - Country:US
Practice Address - Phone:715-392-3300
Practice Address - Fax:715-392-9660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-13
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3215314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20102400Medicaid
WI525613Medicare Oscar/Certification