Provider Demographics
NPI:1831693100
Name:DIVINE SAVIOR HEALTHCARE, INC.
Entity type:Organization
Organization Name:DIVINE SAVIOR HEALTHCARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARLIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-745-5610
Mailing Address - Street 1:2817 NEW PINERY ROAD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901
Mailing Address - Country:US
Mailing Address - Phone:608-745-5603
Mailing Address - Fax:608-742-6098
Practice Address - Street 1:2817 NEW PINERY ROAD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901
Practice Address - Country:US
Practice Address - Phone:608-745-5603
Practice Address - Fax:608-742-6098
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVINE SAVIOR HEALTHCARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33113100Medicaid