Provider Demographics
NPI:1740270735
Name:ST. JOSEPH'S HOME OF OUR LADY OF MT CARMEL INC
Entity type:Organization
Organization Name:ST. JOSEPH'S HOME OF OUR LADY OF MT CARMEL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:EIDSOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-925-8104
Mailing Address - Street 1:9244 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-6602
Mailing Address - Country:US
Mailing Address - Phone:262-694-0080
Mailing Address - Fax:262-925-8137
Practice Address - Street 1:9244 29TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-6602
Practice Address - Country:US
Practice Address - Phone:262-694-0080
Practice Address - Fax:262-925-8137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-21
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2332314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20154500Medicaid
WI20154500Medicaid