Provider Demographics
NPI:1497812697
Name:CLARK COUNTY
Entity Type:Organization
Organization Name:CLARK COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHMITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-229-2172
Mailing Address - Street 1:W4266 STATE RD. 29
Mailing Address - Street 2:
Mailing Address - City:OWEN
Mailing Address - State:WI
Mailing Address - Zip Code:54460
Mailing Address - Country:US
Mailing Address - Phone:715-229-2172
Mailing Address - Fax:
Practice Address - Street 1:W4266 STATE RD. 29
Practice Address - Street 2:
Practice Address - City:OWEN
Practice Address - State:WI
Practice Address - Zip Code:54460
Practice Address - Country:US
Practice Address - Phone:715-229-2172
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Z00000X, 225100000X
WI2387314000000X
WI3014315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21052400Medicaid
WI41011500Medicaid
WI40415200Medicaid
WI20150100Medicaid
WI525403Medicare Oscar/Certification
WI1072370001Medicare NSC