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Organization
SHADY LANE HOME, INC.
Active
Organization
SHADY LANE HOME, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LISA M WETENKAMP (ACCOUNTS RECEIVABLE)
(920) 682-8254
Entity
Organization
Contact information
Practice address
1235 S 24TH ST, MANITOWOC, WI 54220-5516
(920) 682-8254
(920) 682-8315
Mailing address
1235 S 24TH ST, MANITOWOC, WI 54220-5516
(920) 682-8254
(920) 682-8315
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
2250
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
20158400
—
WI
Enumeration date
03/21/2006
Last updated
12/31/2020
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