Provider Demographics
NPI:1336141357
Name:WISCONSIN ILLINOIS SENIOR HOUSING INC.
Entity Type:Organization
Organization Name:WISCONSIN ILLINOIS SENIOR HOUSING INC.
Other - Org Name:GENEVA LAKE MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICARE PROGRAM MONITOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-980-0611
Mailing Address - Street 1:211 S CURTIS ST
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-2052
Mailing Address - Country:US
Mailing Address - Phone:262-248-3145
Mailing Address - Fax:262-248-3564
Practice Address - Street 1:211 S CURTIS ST
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-2052
Practice Address - Country:US
Practice Address - Phone:262-248-3145
Practice Address - Fax:262-248-3564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2693314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20184200Medicaid
WI525565Medicare Oscar/Certification