Provider Demographics
NPI:1134208218
Name:SANNES SKOGDALEN NURSING FACILITY LLC
Entity type:Organization
Organization Name:SANNES SKOGDALEN NURSING FACILITY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO/NHA
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:H
Authorized Official - Last Name:CARLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CFO/NHA
Authorized Official - Phone:608-624-5244
Mailing Address - Street 1:PO BOX 177
Mailing Address - Street 2:101 SUNSHINE BLVD
Mailing Address - City:SOLDIERS GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:54655-0177
Mailing Address - Country:US
Mailing Address - Phone:608-624-5244
Mailing Address - Fax:608-624-3478
Practice Address - Street 1:101 SUNSHINE BLVD
Practice Address - Street 2:
Practice Address - City:SOLDIERS GROVE
Practice Address - State:WI
Practice Address - Zip Code:54655-0177
Practice Address - Country:US
Practice Address - Phone:608-624-5244
Practice Address - Fax:608-624-3478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2607314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI525622OtherMEDICARE PROVIDER NUMBER
WI20193600OtherMEDICAID PROVIDER NUMBER