Provider Demographics
NPI:1639167430
Name:COUNTY OF OUTAGAMIE
Entity Type:Organization
Organization Name:COUNTY OF OUTAGAMIE
Other - Org Name:BREWSTER VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROTHMANN
Authorized Official - Suffix:
Authorized Official - Credentials:NHM ADMINISTRATOR
Authorized Official - Phone:920-832-5400
Mailing Address - Street 1:3300 W BREWSTER ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914
Mailing Address - Country:US
Mailing Address - Phone:920-832-5400
Mailing Address - Fax:920-832-4922
Practice Address - Street 1:3300 W BREWSTER ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914
Practice Address - Country:US
Practice Address - Phone:920-832-5400
Practice Address - Fax:920-832-4922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2371314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20125400Medicaid
WI525574Medicare ID - Type Unspecified