Provider Demographics
NPI:1336324946
Name:STATE OF WISCONSIN
Entity Type:Organization
Organization Name:STATE OF WISCONSIN
Other - Org Name:REHABILIATION SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF REHABILITATION SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:COPLIEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:608-301-9382
Mailing Address - Street 1:317 KNUTSON DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-1133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:317 KNUTSON DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-1133
Practice Address - Country:US
Practice Address - Phone:608-301-9382
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL WISCONSIN CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-02
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41225300Medicaid