Provider Demographics
NPI:1306881594
Name:MUSKEGO NURSING HOME INC.
Entity type:Organization
Organization Name:MUSKEGO NURSING HOME INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMIN/PRES.
Authorized Official - Prefix:MR
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:M
Authorized Official - Last Name:SWANTO
Authorized Official - Suffix:JR
Authorized Official - Credentials:NHA
Authorized Official - Phone:262-679-0246
Mailing Address - Street 1:S. 77-W. 18690 JANESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGO
Mailing Address - State:WI
Mailing Address - Zip Code:53150
Mailing Address - Country:US
Mailing Address - Phone:262-679-0246
Mailing Address - Fax:262-679-9717
Practice Address - Street 1:S. 77-W. 18690 JANESVILLE RD
Practice Address - Street 2:
Practice Address - City:MUSKEGO
Practice Address - State:WI
Practice Address - Zip Code:53150
Practice Address - Country:US
Practice Address - Phone:262-679-0246
Practice Address - Fax:262-679-9717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1089313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20153000Medicaid
WI525686Medicare PIN
WI525686Medicare Oscar/Certification