Provider Demographics
NPI:1225152861
Name:STATE OF WISCONSIN
Entity Type:Organization
Organization Name:STATE OF WISCONSIN
Other - Org Name:WI VETERANS HOME UNION GROVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COMMANDANT
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SEIBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-878-6724
Mailing Address - Street 1:21425G SPRING ST
Mailing Address - Street 2:
Mailing Address - City:UNION GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53182-9707
Mailing Address - Country:US
Mailing Address - Phone:262-878-6700
Mailing Address - Fax:262-878-6758
Practice Address - Street 1:21425G SPRING ST
Practice Address - Street 2:
Practice Address - City:UNION GROVE
Practice Address - State:WI
Practice Address - Zip Code:53182-9707
Practice Address - Country:US
Practice Address - Phone:262-878-6700
Practice Address - Fax:262-878-6758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5024314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20197800Medicaid
WI525688Medicare Oscar/Certification