Provider Demographics
NPI:1609823723
Name:HEARTLAND-WASHINGTON MANOR OF KENOSHA WI LLC
Entity Type:Organization
Organization Name:HEARTLAND-WASHINGTON MANOR OF KENOSHA WI LLC
Other - Org Name:HEARTLAND HEALTH CARE CENTER-WASHINGTON MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-252-5734
Mailing Address - Street 1:333 N SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-2615
Mailing Address - Country:US
Mailing Address - Phone:419-252-5500
Mailing Address - Fax:877-385-9446
Practice Address - Street 1:3100 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1604
Practice Address - Country:US
Practice Address - Phone:262-658-4622
Practice Address - Fax:262-658-1503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2017-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3124314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20200000Medicaid
WI20200000Medicaid