Provider Demographics
NPI:1821091323
Name:MARQUARDT MEMORIAL MANOR, INC.
Entity Type:Organization
Organization Name:MARQUARDT MEMORIAL MANOR, INC.
Other - Org Name:MARQUARDT HEALTH AND REHAB CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHWALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-206-4983
Mailing Address - Street 1:1045 HILL ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3015
Mailing Address - Country:US
Mailing Address - Phone:920-261-0400
Mailing Address - Fax:920-261-4840
Practice Address - Street 1:1020 HILL ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3016
Practice Address - Country:US
Practice Address - Phone:920-261-0400
Practice Address - Fax:920-261-4840
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARQUARDT VILLAGE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-05-27
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2143314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20139200Medicaid
WI534433OtherDEAN HEALTH PLAN
WI20139200Medicaid