Provider Demographics
NPI:1932124898
Name:MILE BLUFF MEDICAL CENTER INC
Entity Type:Organization
Organization Name:MILE BLUFF MEDICAL CENTER INC
Other - Org Name:CREST VIEW NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:OKEEFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-847-6161
Mailing Address - Street 1:612 VIEW ST
Mailing Address - Street 2:
Mailing Address - City:NEW LISBON
Mailing Address - State:WI
Mailing Address - Zip Code:53950-1079
Mailing Address - Country:US
Mailing Address - Phone:608-562-3667
Mailing Address - Fax:608-562-6590
Practice Address - Street 1:612 VIEW ST
Practice Address - Street 2:
Practice Address - City:NEW LISBON
Practice Address - State:WI
Practice Address - Zip Code:53950-1079
Practice Address - Country:US
Practice Address - Phone:608-562-3667
Practice Address - Fax:608-562-6590
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MILE BLUFF MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-13
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2367314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20189600Medicaid
WI20189600Medicaid
WI20189600Medicaid