1336689322 NPI number — ST. JOHN'S LUTHERAN CHURCH, INC.

Table of content: (NPI 1336689322)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336689322 NPI number — ST. JOHN'S LUTHERAN CHURCH, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. JOHN'S LUTHERAN CHURCH, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336689322
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
311 N. LAKE R. P. O BOX 172
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LENA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61048-8712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-369-2690
Provider Business Mailing Address Fax Number:
815-369-2535

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
311 N. LAKE RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LENA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61048-8712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-369-2690
Provider Business Practice Location Address Fax Number:
815-369-2535
Provider Enumeration Date:
02/24/2017

Additional Information

Authorized Official

Authorized Official Last Name:
NOLAN
Authorized Official First Name:
FAWN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHAIRMAN OF THE BOARD
Authorized Official Telephone Number:
815-369-4035

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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