Provider Demographics
NPI:1346208931
Name:COUNTY OF TREMPEALEAU
Entity Type:Organization
Organization Name:COUNTY OF TREMPEALEAU
Other - Org Name:TCHCC-ICFMR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:BORRESON
Authorized Official - Suffix:
Authorized Official - Credentials:NHA, MS
Authorized Official - Phone:715-538-4312
Mailing Address - Street 1:W20298 STATE ROAD 121
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:WI
Mailing Address - Zip Code:54773-9685
Mailing Address - Country:US
Mailing Address - Phone:715-538-4312
Mailing Address - Fax:715-538-2426
Practice Address - Street 1:W20298 STATE ROAD 121
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:WI
Practice Address - Zip Code:54773-9685
Practice Address - Country:US
Practice Address - Phone:715-538-4312
Practice Address - Fax:715-538-2426
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF TREMPEALEAU
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-03
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2987315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21050700Medicaid
WI000062045Medicare PIN