Provider Demographics
NPI:1699767905
Name:COUNTY OF WALWORTH
Entity type:Organization
Organization Name:COUNTY OF WALWORTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NHA
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-741-3600
Mailing Address - Street 1:1922 COUNTY ROAD NN
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-4454
Mailing Address - Country:US
Mailing Address - Phone:262-741-3600
Mailing Address - Fax:262-741-3682
Practice Address - Street 1:1922 COUNTY RD NN
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-4335
Practice Address - Country:US
Practice Address - Phone:262-741-3600
Practice Address - Fax:262-741-3682
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALWORTH COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-22
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2416314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20155000Medicaid
WI20155000Medicaid