Provider Demographics
NPI:1962524272
Name:WISCONSIN LUTHERAN HOME MINISTRIES INC.
Entity type:Organization
Organization Name:WISCONSIN LUTHERAN HOME MINISTRIES INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MERILEE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-425-5353
Mailing Address - Street 1:640 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54022-1537
Mailing Address - Country:US
Mailing Address - Phone:715-425-5353
Mailing Address - Fax:715-425-9911
Practice Address - Street 1:640 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54022-1537
Practice Address - Country:US
Practice Address - Phone:715-425-5353
Practice Address - Fax:715-425-9911
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LUTHERAN HOME
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-06
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3084314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20169900Medicaid
WI20169900Medicaid