NPIMap

Organization Active NPI

County of Wood

Doing business as Edgewater Haven Nursing Home

  • Skilled Nursing Facility
  • Port Edwards, WI
National Provider Identifier
1013915339
Registry record updated Sep 9, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
2369 Issued in WI
Legal business name
COUNTY OF WOOD
Doing business as
Edgewater Haven Nursing Home
Practice address
1351 Wisconsin River Dr
Port Edwards, WI 54469-1041
Phone
(715) 885-8300
Fax
(715) 885-8351
NPI assigned
Jul 11, 2005
Last updated
Sep 9, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 9, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Kyle Theiler, NHA
Title
Administrator
Phone
(715) 885-8324

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X 2369 WI Primary

Addresses

Primary practice location

1351 Wisconsin River Dr
Port Edwards, WI 54469-1041

Mailing address

1351 Wisconsin River Dr
Port Edwards, WI 54469-1099
Phone (715) 885-8300

Other identifiers 1

IdentifierTypeStateIssuer
20131100MedicaidWI

Other names 1

  • Edgewater Haven Nursing Home Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20111006000277 WI Part A Provider - Skilled Nursing Facility 3476554692 Practice locations: Port Edwards, WI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1013915339. Details of each certification follow.

Skilled nursing facility certification: CCN 525088

Legal name
COUNTY OF WOOD
Doing business as
EDGEWATER HAVEN NURSING HOME
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Jan 1, 1967
Last certification
Jun 26, 2024
Beds
50
Ownership / control type
County
Multi-facility organization
Wood County
Organization structure
GovernmentNon-profit
Incorporated
Jun 15, 1885 in WI
Enrollment address
1351 Wisconsin River Dr
Port Edwards, WI 54469-1041
Nursing home name
EDGEWATER HAVEN NURSING HOME

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Care Compare: Nursing home

Medicare Care Compare
Listed as
Edgewater Haven Nursing HomeCCN 525088 · All quality measures
Overall star rating
5 of 5
Health inspections
4 of 5
Staffing
5 of 5
Quality measures
5 of 5
Type
Medicare and Medicaid
Ownership
Government - County
Certified
Jan 1, 1967
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
5045.5 residents per day on average

Processed by Care Compare on Aug 1, 2026.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
52D0693021Edgewater Haven Nursing Home1351 Wisconsin River Dr, Port Edwards, WI 54469Certificate of waiverAug 31, 2026

National Provider Directory

National Provider Directory
Tax ID family
Wood County HLTH Dept10 organizations share this tax ID, including this one

Other organizations with this tax ID 9

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1351 Wisconsin River Dr
Port Edwards, WI 54469
Phone (715) 885-8300

Ownership & related parties

All disclosed owners & managing parties 4

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Heather Gehrt Individual Corporate Officer Dec 31, 2015
W-2 Managing Employee Mar 4, 2002
County of Wood Organization, Port Edwards, WI Other Nov 15, 2011 100%
Keshni Ramnanan Individual W-2 Managing EmployeeMD; Jul 1, 2024
Justin Cieslewicz Individual Corporate OfficerCorporate Secretary Jul 24, 2023 100%
Corporate DirectorAdminstrator Jul 24, 2023 100%
W-2 Managing EmployeeAd; Jul 24, 2023 100%

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Norwood Health CenterMarshfield, WI, CCN 524019 Hospital Operational/Managerial Control (100%)
Other (100%)		 Aug 23, 2015
Jan 20, 2016

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

  • County of Wood

    dba Norwood Health Center

    • Psychiatric Hospital
    • Marshfield, WI
    • NPI 1508840844

    Operational/Managerial Control, Other

    CMS ownership

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1121040000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1662681600000",
    "number": "1013915339",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1351 WISCONSIN RIVER DR",
            "city": "PORT EDWARDS",
            "state": "WI",
            "postal_code": "544691099",
            "telephone_number": "715-885-8300",
            "fax_number": "715-885-8351"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1351 WISCONSIN RIVER DR",
            "city": "PORT EDWARDS",
            "state": "WI",
            "postal_code": "544691041",
            "telephone_number": "715-885-8300",
            "fax_number": "715-885-8351"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COUNTY OF WOOD",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-07-11",
        "last_updated": "2022-09-09",
        "certification_date": "2022-09-09",
        "status": "A",
        "authorized_official_last_name": "THEILER",
        "authorized_official_first_name": "KYLE",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "715-885-8324",
        "authorized_official_credential": "NHA"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "WI",
            "license": "2369",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "20131100",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Edgewater Haven Nursing Home",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Edgewater Haven Nursing Home",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Port Edwards, WI

Sources for this page

Verify at the official NPI Registry.