Provider Demographics
NPI:1699762625
Name:PARK MANOR, LTD.
Entity type:Organization
Organization Name:PARK MANOR, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-762-2449
Mailing Address - Street 1:250 LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:PARK FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54552-1431
Mailing Address - Country:US
Mailing Address - Phone:715-762-2449
Mailing Address - Fax:715-762-3321
Practice Address - Street 1:250 LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:PARK FALLS
Practice Address - State:WI
Practice Address - Zip Code:54552-1431
Practice Address - Country:US
Practice Address - Phone:715-762-2449
Practice Address - Fax:715-762-3321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2019-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X, 332BN1400X, 335E00000X
WI2452314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41224900Medicaid
WI20145000Medicaid
525612Medicare UPIN