Provider Demographics
NPI:1295939049
Name:SHELL LAKE SNF LLC
Entity type:Organization
Organization Name:SHELL LAKE SNF LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JONATHON
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-828-7310
Mailing Address - Street 1:PO BOX 642
Mailing Address - Street 2:
Mailing Address - City:SAUK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56379-0642
Mailing Address - Country:US
Mailing Address - Phone:320-828-7310
Mailing Address - Fax:320-764-2665
Practice Address - Street 1:802 E CTY HWY B
Practice Address - Street 2:
Practice Address - City:SHELL LAKE
Practice Address - State:WI
Practice Address - Zip Code:54871
Practice Address - Country:US
Practice Address - Phone:715-468-4292
Practice Address - Fax:715-468-4232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI314000000X
WI2748313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2748OtherBUSINESS LICENSE NUMBER
WI525553Medicare Oscar/Certification