Provider Demographics
NPI:1265429278
Name:COUNTY OF GRANT - ORCHARD MANOR FDD
Entity type:Organization
Organization Name:COUNTY OF GRANT - ORCHARD MANOR FDD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAINES
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:608-723-2113
Mailing Address - Street 1:8800 HWY 61
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:WI
Mailing Address - Zip Code:53813-9306
Mailing Address - Country:US
Mailing Address - Phone:608-723-2113
Mailing Address - Fax:608-723-2210
Practice Address - Street 1:8800 HWY 61
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:WI
Practice Address - Zip Code:53813-9306
Practice Address - Country:US
Practice Address - Phone:608-723-2113
Practice Address - Fax:608-723-2210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3109315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
0834840001OtherDMERC
WI21050300Medicaid
525290Medicare ID - Type Unspecified