Provider Demographics
NPI:1013915339
Name:COUNTY OF WOOD
Entity Type:Organization
Organization Name:COUNTY OF WOOD
Other - Org Name:EDGEWATER HAVEN NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:THEILER
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:715-885-8324
Mailing Address - Street 1:1351 WISCONSIN RIVER DR
Mailing Address - Street 2:
Mailing Address - City:PORT EDWARDS
Mailing Address - State:WI
Mailing Address - Zip Code:54469-1099
Mailing Address - Country:US
Mailing Address - Phone:715-885-8300
Mailing Address - Fax:715-885-8351
Practice Address - Street 1:1351 WISCONSIN RIVER DR
Practice Address - Street 2:
Practice Address - City:PORT EDWARDS
Practice Address - State:WI
Practice Address - Zip Code:54469-1041
Practice Address - Country:US
Practice Address - Phone:715-885-8300
Practice Address - Fax:715-885-8351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-11
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2369314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20131100Medicaid
WI20131100Medicaid