Provider Demographics
NPI:1932107463
Name:VILLAGE OF PRAIRIE FARM
Entity Type:Organization
Organization Name:VILLAGE OF PRAIRIE FARM
Other - Org Name:PIONEER NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUHR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-832-3003
Mailing Address - Street 1:530 RIVER AVENUE SOUTH
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE FARM
Mailing Address - State:WI
Mailing Address - Zip Code:54762
Mailing Address - Country:US
Mailing Address - Phone:715-455-1178
Mailing Address - Fax:715-455-1044
Practice Address - Street 1:530 RIVER AVENUE SOUTH
Practice Address - Street 2:
Practice Address - City:PRAIRIE FARM
Practice Address - State:WI
Practice Address - Zip Code:54762
Practice Address - Country:US
Practice Address - Phone:715-455-1178
Practice Address - Fax:715-455-1044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1056314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20156100Medicaid
WI525652Medicare ID - Type Unspecified