Basic Information
| Provider Information | |||||||||
| NPI: | 1215984307 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MANOR CARE OF SHAWANO WI LLC | ||||||||
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| OtherOrganizationName: | MANORCARE HEALTH SERVICES - SHAWANO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 N SUMMIT ST | ||||||||
| Address2: | 4TH FLOOR ATTN BARRY LAZARUS | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436041531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192525541 | ||||||||
| FaxNumber: | 4192525548 | ||||||||
| Practice Location | |||||||||
| Address1: | 1436 S LINCOLN ST | ||||||||
| Address2: | |||||||||
| City: | SHAWANO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541663427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7155266111 | ||||||||
| FaxNumber: | 7155245708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 02/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | LAZARUS | ||||||||
| AuthorizedOfficialFirstName: | BARRY | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT-REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 4192525541 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 3175 | WI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 20200500 | 05 | WI | MEDICAID |