Provider Demographics
NPI:1578559456
Name:SANTA MARIA NURSING HOME, INC.
Entity Type:Organization
Organization Name:SANTA MARIA NURSING HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DESOTELL
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:920-432-5231
Mailing Address - Street 1:430 S CLAY ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3807
Mailing Address - Country:US
Mailing Address - Phone:920-432-5231
Mailing Address - Fax:920-432-9881
Practice Address - Street 1:430 S CLAY ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3807
Practice Address - Country:US
Practice Address - Phone:920-432-5231
Practice Address - Fax:920-432-9881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1134314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1134OtherLICENSE NUMBER
WI20152400Medicaid
WI525590Medicare ID - Type Unspecified