Basic Information
| Provider Information | |||||||||
| NPI: | 1013678770 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COUNTY OF LA CROSSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3501 PARK LANE DR | ||||||||
| Address2: | |||||||||
| City: | LA CROSSE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546017747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087894800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3501 PARK LANE DR | ||||||||
| Address2: | |||||||||
| City: | LA CROSSE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546017747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087894800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2022 | ||||||||
| LastUpdateDate: | 01/05/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KRAMER | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | NURSING HOME ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6085199357 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COUNTY OF LA CROSSE | ||||||||
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| AuthorizedOfficialCredential: | NHA | ||||||||
| NPICertificationDate: | 01/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310500000X | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | 20128700 | 05 | WI | MEDICAID |