Provider Demographics
NPI:1902895592
Name:FOUR WINDS MANOR, INC.
Entity type:Organization
Organization Name:FOUR WINDS MANOR, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:RETRUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-845-6465
Mailing Address - Street 1:303 S JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-1415
Mailing Address - Country:US
Mailing Address - Phone:608-845-6465
Mailing Address - Fax:608-848-8315
Practice Address - Street 1:303 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:WI
Practice Address - Zip Code:53593-1415
Practice Address - Country:US
Practice Address - Phone:608-845-6465
Practice Address - Fax:608-848-8315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20154000Medicaid
WI20154000Medicaid