Provider Demographics
NPI:1528056819
Name:SAUK COUNTY
Entity type:Organization
Organization Name:SAUK COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:KATHLEEN
Authorized Official - Last Name:DIETZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-524-7500
Mailing Address - Street 1:1051 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:REEDSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53959-2321
Mailing Address - Country:US
Mailing Address - Phone:608-524-7500
Mailing Address - Fax:608-524-7579
Practice Address - Street 1:1051 CLARK ST
Practice Address - Street 2:
Practice Address - City:REEDSBURG
Practice Address - State:WI
Practice Address - Zip Code:53959-2321
Practice Address - Country:US
Practice Address - Phone:608-524-7500
Practice Address - Fax:608-524-7579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2397314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20132500Medicaid
WI21052700Medicaid
WI506713OtherDEAN HEALTH PLAN HMO
WI525114Medicare UPIN
WI20132500Medicaid
WI00057122Medicare ID - Type UnspecifiedMEDICARE B / WPS