Provider Demographics
NPI:1760470819
Name:WAUNAKEE MANOR HEALTH CARE CENTER, INC.
Entity Type:Organization
Organization Name:WAUNAKEE MANOR HEALTH CARE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KRUCHTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-849-5016
Mailing Address - Street 1:801 S KLEIN DR
Mailing Address - Street 2:
Mailing Address - City:WAUNAKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53597-1575
Mailing Address - Country:US
Mailing Address - Phone:608-849-5016
Mailing Address - Fax:608-850-6878
Practice Address - Street 1:801 S KLEIN DR
Practice Address - Street 2:
Practice Address - City:WAUNAKEE
Practice Address - State:WI
Practice Address - Zip Code:53597-1575
Practice Address - Country:US
Practice Address - Phone:608-849-5016
Practice Address - Fax:608-850-6878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2450314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20131700Medicaid
WI20131700Medicaid