Provider Demographics
NPI:1598766784
Name:SISTERS OF CHARITY OF OUR LADY MOTHER OF THE CHURCH
Entity Type:Organization
Organization Name:SISTERS OF CHARITY OF OUR LADY MOTHER OF THE CHURCH
Other - Org Name:ST. ELIZABETH NURSING HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHWALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-206-4983
Mailing Address - Street 1:1045 HILL ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3015
Mailing Address - Country:US
Mailing Address - Phone:920-261-0400
Mailing Address - Fax:920-261-4840
Practice Address - Street 1:109 S ATWOOD AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-4098
Practice Address - Country:US
Practice Address - Phone:608-752-6709
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0624314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20167600Medicaid
WI20167600Medicaid