Provider Demographics
NPI:1902877632
Name:CAPITOL LAKES INC.
Entity Type:Organization
Organization Name:CAPITOL LAKES INC.
Other - Org Name:CAPITOL LAKES INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCLEMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-857-7215
Mailing Address - Street 1:333 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-2777
Mailing Address - Country:US
Mailing Address - Phone:608-283-2141
Mailing Address - Fax:
Practice Address - Street 1:333 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-2777
Practice Address - Country:US
Practice Address - Phone:608-283-2141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20124200Medicaid
WI525305Medicare ID - Type Unspecified