Provider Demographics
NPI:1457312209
Name:CHRISTIAN HOME AND REHABILITATION CENTER, INC.
Entity Type:Organization
Organization Name:CHRISTIAN HOME AND REHABILITATION CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSING HOME ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WIRKUS
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:920-324-9051
Mailing Address - Street 1:452 FOX LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963-1761
Mailing Address - Country:US
Mailing Address - Phone:920-324-9051
Mailing Address - Fax:920-324-4724
Practice Address - Street 1:452 FOX LAKE RD
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-1761
Practice Address - Country:US
Practice Address - Phone:920-324-9051
Practice Address - Fax:920-324-4724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0010292310400000X
WI0525314000000X
WI320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20155500Medicaid
WI20155500Medicaid