Provider Demographics
NPI:1336109776
Name:MEDICAID
Entity Type:Organization
Organization Name:MEDICAID
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN
Authorized Official - Prefix:MISS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FARRAGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-450-8323
Mailing Address - Street 1:1125 GENEVA RD
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1505
Mailing Address - Country:US
Mailing Address - Phone:920-450-8323
Mailing Address - Fax:
Practice Address - Street 1:1125 GENEVA RD
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1505
Practice Address - Country:US
Practice Address - Phone:920-450-8323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI311Z00000X, 3140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Not Answered3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric