Provider Demographics
NPI:1215984307
Name:MANOR CARE OF SHAWANO WI LLC
Entity type:Organization
Organization Name:MANOR CARE OF SHAWANO WI LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT-REIMBURSEMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAZARUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-252-5541
Mailing Address - Street 1:333 N SUMMIT ST
Mailing Address - Street 2:4TH FLOOR ATTN BARRY LAZARUS
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1531
Mailing Address - Country:US
Mailing Address - Phone:419-252-5541
Mailing Address - Fax:419-252-5548
Practice Address - Street 1:1436 S LINCOLN ST
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-3427
Practice Address - Country:US
Practice Address - Phone:715-526-6111
Practice Address - Fax:715-524-5708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3175314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20200500Medicaid
WI525335Medicare Oscar/Certification