Provider Demographics
NPI:1144223538
Name:NORTHLAND LUTHERAN HOME HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:NORTHLAND LUTHERAN HOME HEALTH SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-732-0155
Mailing Address - Street 1:925 PINE BEACH RD
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-4227
Mailing Address - Country:US
Mailing Address - Phone:715-735-6222
Mailing Address - Fax:715-735-6221
Practice Address - Street 1:925 PINE BEACH RD
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-4227
Practice Address - Country:US
Practice Address - Phone:715-735-6222
Practice Address - Fax:715-735-6221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI256251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2828102Medicaid
WI415-27500Medicaid
MI2828102Medicaid