Provider Demographics
NPI:1043463961
Name:WISCONSIN ILLINOIS SENIOR HOUSING INC.
Entity type:Organization
Organization Name:WISCONSIN ILLINOIS SENIOR HOUSING INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICARE PROGRAM MONITOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-980-0611
Mailing Address - Street 1:3271 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:EAST TROY
Mailing Address - State:WI
Mailing Address - Zip Code:53120-1147
Mailing Address - Country:US
Mailing Address - Phone:262-642-3995
Mailing Address - Fax:262-642-3930
Practice Address - Street 1:3271 NORTH ST
Practice Address - Street 2:
Practice Address - City:EAST TROY
Practice Address - State:WI
Practice Address - Zip Code:53120-1147
Practice Address - Country:US
Practice Address - Phone:262-642-3995
Practice Address - Fax:262-642-3930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-23
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI525561Medicare PIN
525561Medicare Oscar/Certification