Provider Demographics
NPI:1336145291
Name:WOODLAND VILLAGE, INC.
Entity Type:Organization
Organization Name:WOODLAND VILLAGE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-842-2191
Mailing Address - Street 1:430 MANOR DR
Mailing Address - Street 2:
Mailing Address - City:SURING
Mailing Address - State:WI
Mailing Address - Zip Code:54174-9182
Mailing Address - Country:US
Mailing Address - Phone:920-842-2191
Mailing Address - Fax:920-842-2176
Practice Address - Street 1:430 MANOR DR
Practice Address - Street 2:
Practice Address - City:SURING
Practice Address - State:WI
Practice Address - Zip Code:54174-9182
Practice Address - Country:US
Practice Address - Phone:920-842-2191
Practice Address - Fax:920-842-2176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-24
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2698314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20111200Medicaid
WI20111200Medicaid