Provider Demographics
NPI:1649275991
Name:RACINE COUNTY
Entity type:Organization
Organization Name:RACINE COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COUNTY EXECUTIVE
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCREYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-636-3273
Mailing Address - Street 1:3205 WOOD RD
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-5048
Mailing Address - Country:US
Mailing Address - Phone:262-554-6440
Mailing Address - Fax:262-554-5119
Practice Address - Street 1:3205 WOOD RD
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-5048
Practice Address - Country:US
Practice Address - Phone:262-554-6440
Practice Address - Fax:262-554-5119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2925314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20130700Medicaid
WI525608Medicare ID - Type UnspecifiedMEDICARE #