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Organization
COUNTY OF RICHLAND
Active
Organization
COUNTY OF RICHLAND
Active
Other names
Pine Valley Community Village
Organization subpart
No
Provider details
NPI number
Authorized official
SHAPONDA JIMERSON ADM (ADMINISTRATOR)
(608) 647-2138
Entity
Organization
Contact information
Practice address
25951 CIRCLE VIEW DR, RICHLAND CENTER, WI 53581-4013
(608) 647-2138
(608) 647-8955
Mailing address
25951 CIRCLE VIEW DR, RICHLAND CENTER, WI 53581-4013
(608) 647-2138
(608) 647-8955
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
2365
WI
332BN1400X
Nursing Facility Supplies (DME)
2365
WI
332BP3500X
Parenteral & Enteral Nutrition Supplies (DME)
2365
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
20155800
—
WI
Enumeration date
07/21/2005
Last updated
02/07/2024
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