Provider Demographics
NPI:1881690873
Name:CHIPPEWA MANOR NURSING AND REHABILITATION CORPORATION
Entity Type:Organization
Organization Name:CHIPPEWA MANOR NURSING AND REHABILITATION CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:THORSNESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-723-4437
Mailing Address - Street 1:222 CHAPMAN RD
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-3253
Mailing Address - Country:US
Mailing Address - Phone:715-723-4437
Mailing Address - Fax:715-723-0524
Practice Address - Street 1:222 CHAPMAN RD
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-3253
Practice Address - Country:US
Practice Address - Phone:715-723-4437
Practice Address - Fax:715-723-0524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2627314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20105700Medicaid
WI20105700Medicaid