Provider Demographics
NPI:1003988049
Name:COUNTY OF SHEBOYGAN
Entity type:Organization
Organization Name:COUNTY OF SHEBOYGAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:TAUBENHEIM
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:920-893-9205
Mailing Address - Street 1:N7135 ROCKY KNOLL PKWY
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073-3103
Mailing Address - Country:US
Mailing Address - Phone:920-467-6464
Mailing Address - Fax:920-893-0500
Practice Address - Street 1:N7135 ROCKY KNOLL PKWY
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073-3103
Practice Address - Country:US
Practice Address - Phone:920-467-6464
Practice Address - Fax:920-893-0500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2362314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41666800Medicaid
WI32670800OtherPHYSICIAN MEDICAID
WI20141300Medicaid
WI0309670001Medicare NSC
525337Medicare ID - Type Unspecified