Provider Demographics
NPI:1649273350
Name:MANAWA COMMUNITY NURSING CENTER INC.
Entity type:Organization
Organization Name:MANAWA COMMUNITY NURSING CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MATICEK
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:920-596-2566
Mailing Address - Street 1:400 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MANAWA
Mailing Address - State:WI
Mailing Address - Zip Code:54949-9227
Mailing Address - Country:US
Mailing Address - Phone:920-596-2566
Mailing Address - Fax:920-596-2588
Practice Address - Street 1:400 E 4TH ST
Practice Address - Street 2:
Practice Address - City:MANAWA
Practice Address - State:WI
Practice Address - Zip Code:54949
Practice Address - Country:US
Practice Address - Phone:920-596-2566
Practice Address - Fax:920-596-2588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2616314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20105000Medicaid
WI20105000Medicaid