Provider Demographics
NPI:1144229055
Name:COUNTY OF RICHLAND
Entity Type:Organization
Organization Name:COUNTY OF RICHLAND
Other - Org Name:PINE VALLEY COMMUNITY VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAPONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:JIMERSON
Authorized Official - Suffix:
Authorized Official - Credentials:ADM
Authorized Official - Phone:608-647-2138
Mailing Address - Street 1:25951 CIRCLE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:RICHLAND CENTER
Mailing Address - State:WI
Mailing Address - Zip Code:53581-4013
Mailing Address - Country:US
Mailing Address - Phone:608-647-2138
Mailing Address - Fax:608-647-8955
Practice Address - Street 1:25951 CIRCLE VIEW DR
Practice Address - Street 2:
Practice Address - City:RICHLAND CENTER
Practice Address - State:WI
Practice Address - Zip Code:53581-4013
Practice Address - Country:US
Practice Address - Phone:608-647-2138
Practice Address - Fax:608-647-8955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2365314000000X, 332BN1400X, 332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20155800Medicaid
WI0851570001Medicare NSC
WI20155800Medicaid