Basic Information
| Provider Information | |||||||||
| NPI: | 1134208218 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SANNES SKOGDALEN NURSING FACILITY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SANNES SKOGDALEN HEIM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 177 | ||||||||
| Address2: | 101 SUNSHINE BLVD | ||||||||
| City: | SOLDIERS GROVE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546550177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086245244 | ||||||||
| FaxNumber: | 6086243478 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 SUNSHINE BLVD | ||||||||
| Address2: | |||||||||
| City: | SOLDIERS GROVE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546550177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086245244 | ||||||||
| FaxNumber: | 6086243478 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 12/26/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CARLEY | ||||||||
| AuthorizedOfficialFirstName: | JACQUELINE | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO/NHA | ||||||||
| AuthorizedOfficialTelephone: | 6086245244 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CFO/NHA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 2607 | WI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 525622 | 01 | WI | MEDICARE PROVIDER NUMBER | OTHER | 20193600 | 01 | WI | MEDICAID PROVIDER NUMBER | OTHER |