Provider Demographics
NPI:1700884020
Name:WISCONSIN ILLINOIS SENIOR HOUSING INC.
Entity Type:Organization
Organization Name:WISCONSIN ILLINOIS SENIOR HOUSING INC.
Other - Org Name:MONTELLO CARE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL PROGRAM MONITOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-980-0611
Mailing Address - Street 1:251 FOREST LN
Mailing Address - Street 2:
Mailing Address - City:MONTELLO
Mailing Address - State:WI
Mailing Address - Zip Code:53949-9380
Mailing Address - Country:US
Mailing Address - Phone:608-297-2153
Mailing Address - Fax:608-297-9328
Practice Address - Street 1:251 FOREST LN
Practice Address - Street 2:
Practice Address - City:MONTELLO
Practice Address - State:WI
Practice Address - Zip Code:53949-9380
Practice Address - Country:US
Practice Address - Phone:608-297-2153
Practice Address - Fax:608-297-9328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-11
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI314000000X314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20186200Medicaid
WI20186200Medicaid