Provider Demographics
NPI:1558615815
Name:STATE OF WISCONSIN
Entity Type:Organization
Organization Name:STATE OF WISCONSIN
Other - Org Name:THE WISCONSIN VETERANS HOME AT CHIPPEWA FALLS
Other - Org Type:Other Name
Authorized Official - Title/Position:HOMES DIVISION ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:C
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-294-7827
Mailing Address - Street 1:2175 E PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-3511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2175 E PARK AVE
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-3511
Practice Address - Country:US
Practice Address - Phone:715-720-6775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-07
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5039314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100028125Medicaid
WI100028125Medicaid