Provider Demographics
NPI:1790817641
Name:COUNTY OF TREMPEALEAU
Entity Type:Organization
Organization Name:COUNTY OF TREMPEALEAU
Other - Org Name:RIVER WAY NORTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEETZ
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:715-538-4312
Mailing Address - Street 1:W20410 STATE ROAD 121
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:WI
Mailing Address - Zip Code:54773-9147
Mailing Address - Country:US
Mailing Address - Phone:715-538-4312
Mailing Address - Fax:715-538-2426
Practice Address - Street 1:W21011 STATE ROAD 121
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:WI
Practice Address - Zip Code:54747
Practice Address - Country:US
Practice Address - Phone:715-985-3673
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF TREMPEALEAU
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-09
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11601311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11601OtherADULT FAMILY HOME
WI000062045Medicare PIN