1649266404 NPI number — FOND DU LAC LUTHERAN HOME, INC.

Table of content: (NPI 1649266404)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649266404 NPI number — FOND DU LAC LUTHERAN HOME, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOND DU LAC LUTHERAN HOME, 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:
WELLNESS AND REHAB CENTER
Provider Other Organization Name Type Code:
3
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:
1649266404
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
244 N MACY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOND DU LAC
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54935-3362
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-951-9520
Provider Business Mailing Address Fax Number:
920-921-0819

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
244 N MACY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOND DU LAC
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54935-3362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-951-9520
Provider Business Practice Location Address Fax Number:
920-921-0819
Provider Enumeration Date:
09/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MARKS
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
920-261-0400

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 0047 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 20129000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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