Provider Demographics
NPI:1750324687
Name:COUNTY OF VERNON
Entity Type:Organization
Organization Name:COUNTY OF VERNON
Other - Org Name:VERNON MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NURSING HOME ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-637-5404
Mailing Address - Street 1:310 FAIRLAND DR
Mailing Address - Street 2:
Mailing Address - City:VIROQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54665
Mailing Address - Country:US
Mailing Address - Phone:608-637-5400
Mailing Address - Fax:608-637-5441
Practice Address - Street 1:310 FAIRLAND DR
Practice Address - Street 2:
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665-6134
Practice Address - Country:US
Practice Address - Phone:608-637-5400
Practice Address - Fax:608-637-5441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2678314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20157900Medicaid
WI525562Medicare ID - Type Unspecified