Provider Demographics
NPI:1164408266
Name:LAFAYETTE COUNTY
Entity Type:Organization
Organization Name:LAFAYETTE COUNTY
Other - Org Name:LAFAYETTE MANOR
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:CHIKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-776-4472
Mailing Address - Street 1:719 E CATHERINE ST
Mailing Address - Street 2:
Mailing Address - City:DARLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53530-1330
Mailing Address - Country:US
Mailing Address - Phone:608-776-4472
Mailing Address - Fax:608-776-4473
Practice Address - Street 1:719 E CATHERINE ST
Practice Address - Street 2:
Practice Address - City:DARLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53530-1330
Practice Address - Country:US
Practice Address - Phone:608-776-4472
Practice Address - Fax:608-776-4473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-20
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2448314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20153500Medicaid
WI525362Medicare Oscar/Certification