Provider Demographics
NPI:1437561669
Name:BACKMAN, WAYNE (2128-19)
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:
Last Name:BACKMAN
Suffix:
Gender:M
Credentials:2128-19
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N MORRIS ST
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-1857
Mailing Address - Country:US
Mailing Address - Phone:608-873-5651
Mailing Address - Fax:
Practice Address - Street 1:400 N MORRIS ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-1857
Practice Address - Country:US
Practice Address - Phone:608-873-5651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-22
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2128-19314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility