Provider Demographics
NPI:1518926211
Name:SHADY LANE HOME, INC.
Entity Type:Organization
Organization Name:SHADY LANE HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS RECEIVABLE
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WETENKAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-682-8254
Mailing Address - Street 1:1235 S 24TH ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-5516
Mailing Address - Country:US
Mailing Address - Phone:920-682-8254
Mailing Address - Fax:920-682-8315
Practice Address - Street 1:1235 S 24TH ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-5516
Practice Address - Country:US
Practice Address - Phone:920-682-8254
Practice Address - Fax:920-682-8315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2250314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20158400Medicaid
WI525575Medicare ID - Type Unspecified