Provider Demographics
NPI:1659373348
Name:PETERSEN HEALTH CARE OF WI, INC.
Entity Type:Organization
Organization Name:PETERSEN HEALTH CARE OF WI, INC.
Other - Org Name:FRIENDLY VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NURSING HOME ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLARD
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:715-365-6449
Mailing Address - Street 1:900 BOYCE DR
Mailing Address - Street 2:P.O. BOX 857
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501-3835
Mailing Address - Country:US
Mailing Address - Phone:715-365-6900
Mailing Address - Fax:715-365-6665
Practice Address - Street 1:900 BOYCE DR
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-3835
Practice Address - Country:US
Practice Address - Phone:715-365-6900
Practice Address - Fax:715-365-6665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2751314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20114800Medicaid
WI20114800Medicaid