Provider Demographics
NPI:1063756286
Name:WISCONSIN ILLINOIS SENIOR HOUSING INC.
Entity type:Organization
Organization Name:WISCONSIN ILLINOIS SENIOR HOUSING INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-980-0611
Mailing Address - Street 1:313 STOUGHTON RD
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:WI
Mailing Address - Zip Code:53534-1132
Mailing Address - Country:US
Mailing Address - Phone:608-884-1330
Mailing Address - Fax:608-884-1331
Practice Address - Street 1:313 STOUGHTON RD
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:WI
Practice Address - Zip Code:53534-1132
Practice Address - Country:US
Practice Address - Phone:608-884-1330
Practice Address - Fax:608-884-1331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2235314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI525241Medicare Oscar/Certification