Provider Demographics
NPI:1720088495
Name:COUNTY OF SHAWANO
Entity Type:Organization
Organization Name:COUNTY OF SHAWANO
Other - Org Name:MAPLE LANE HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACCOUNTANT/CONTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBBRA
Authorized Official - Middle Name:R
Authorized Official - Last Name:KESSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-526-3158
Mailing Address - Street 1:N4231 STATE HIGHWAY 22
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-6130
Mailing Address - Country:US
Mailing Address - Phone:715-526-3158
Mailing Address - Fax:715-526-6823
Practice Address - Street 1:N4231 STATE HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-6130
Practice Address - Country:US
Practice Address - Phone:715-526-3158
Practice Address - Fax:715-526-6823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2994315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21051100Medicaid