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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