Shady Lane Home, Inc.

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

License

2250 Issued in WI

Legal business name

SHADY LANE HOME, INC.

Practice address

1235 S 24TH St
Manitowoc, WI 54220-5516

Phone

(920) 682-8254

Fax

(920) 682-8315

NPI assigned

Mar 21, 2006

Last updated

Dec 31, 2020By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Lisa M Wetenkamp

Title

Accounts Receivable

Phone

(920) 682-8254

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in WI

Enrollment records 1

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1518926211. Details of each certification follow.

• CCN 525575 Skilled nursing facility · Active · Details

Skilled nursing facility certification: CCN 525575

Legal name

SHADY LANE HOME, INC.

Certification status

Active

Provider type (POS)

Nursing home – SNF/NF dual certification

Participating since

Oct 1, 1995

Last certification

Apr 16, 2025

Beds

50

Ownership / control type

Nonprofit Corporation

Organization structure

CorporationNon-profit

Enrollment address

1235 S 24TH St
Manitowoc, WI 54220-5516

Nursing home name

SHADY LANE NURSING CARE CENTER

Listed as

Shady Lane Nursing Care CenterCCN 525575 · All quality measures

Overall star rating

5 of 5

Health inspections

4 of 5

Staffing

5 of 5

Quality measures

3 of 5

Type

Medicare and Medicaid

Ownership

Non profit - Corporation

Certified

Oct 1, 1995

Medicare certification status

ActiveFrom the Provider of Services file

Certified beds

5043.5 residents per day on average

Processed by Care Compare on Aug 1, 2026.

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

CLIA laboratory certificates

All disclosed owners & managing parties 13

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

Affiliated clinicians 4

Clinicians who list this facility as an affiliation in Medicare Care Compare.

• Kelly Dawson, APNP

  • Nurse Practitioner
  • Sheboygan, WI
  • NPI 1346663838

  Nursing home

  Care Compare affiliation
• Alfredo Diaz, MD

  • Internal Medicine Physician
  • Two Rivers, WI
  • NPI 1902911159

  Nursing home

  Care Compare affiliation
• Tresa A Teehan, MD

  • Internal Medicine Physician
  • Two Rivers, WI
  • NPI 1144337247

  Nursing home

  Care Compare affiliation
• Richard W Theobald, MD

  • Internal Medicine Physician
  • Two Rivers, WI
  • NPI 1952418063

  Nursing home

  Care Compare affiliation

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

{
    "created_epoch": "1142899200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1609372800000",
    "number": "1518926211",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1235 S 24TH ST",
            "city": "MANITOWOC",
            "state": "WI",
            "postal_code": "542205516",
            "telephone_number": "920-682-8254",
            "fax_number": "920-682-8315"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1235 S 24TH ST",
            "city": "MANITOWOC",
            "state": "WI",
            "postal_code": "542205516",
            "telephone_number": "920-682-8254",
            "fax_number": "920-682-8315"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHADY LANE HOME, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-03-21",
        "last_updated": "2020-12-31",
        "certification_date": "2020-12-31",
        "status": "A",
        "authorized_official_last_name": "WETENKAMP",
        "authorized_official_first_name": "LISA",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "ACCOUNTS RECEIVABLE",
        "authorized_official_telephone_number": "920-682-8254"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "WI",
            "license": "2250",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "20158400",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Skilled Nursing Facility in Manitowoc, WI
• Providers in Manitowoc, WI by specialty
• Skilled Nursing Facility in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 31, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.