Provider Demographics
NPI:1376530592
Name:NEW GLARUS HOME, INC
Entity Type:Organization
Organization Name:NEW GLARUS HOME, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:L
Authorized Official - Last Name:GOEPFERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-527-2126
Mailing Address - Street 1:600 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW GLARUS
Mailing Address - State:WI
Mailing Address - Zip Code:53574-9776
Mailing Address - Country:US
Mailing Address - Phone:608-527-2126
Mailing Address - Fax:608-527-5365
Practice Address - Street 1:600 2ND AVE
Practice Address - Street 2:
Practice Address - City:NEW GLARUS
Practice Address - State:WI
Practice Address - Zip Code:53574-9776
Practice Address - Country:US
Practice Address - Phone:608-527-2126
Practice Address - Fax:608-527-5365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-03
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2605314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20104200Medicaid
WI525630Medicare ID - Type Unspecified