Provider Demographics
NPI:1215011317
Name:LINCOLN LUTHERAN HOME OF RACINE INC
Entity Type:Organization
Organization Name:LINCOLN LUTHERAN HOME OF RACINE INC
Other - Org Name:LINCOLN VILLAGE CONVALESCENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:GLEN
Authorized Official - Last Name:APPLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-898-2722
Mailing Address - Street 1:2000 DOMANIK DRIVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53404
Mailing Address - Country:US
Mailing Address - Phone:262-633-0500
Mailing Address - Fax:262-633-3045
Practice Address - Street 1:1700 CA BECKER DRIVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406
Practice Address - Country:US
Practice Address - Phone:262-637-9751
Practice Address - Fax:262-633-3045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2269314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20129400Medicaid
WI20129400Medicaid