Provider Demographics
NPI:1346543246
Name:DIVINE SAVIOR HEALTHCARE
Entity Type:Organization
Organization Name:DIVINE SAVIOR HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATHLETIC TRAINING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLISON
Authorized Official - Suffix:
Authorized Official - Credentials:LAT
Authorized Official - Phone:608-745-6290
Mailing Address - Street 1:2817 NEW PINERY RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-9240
Mailing Address - Country:US
Mailing Address - Phone:608-745-6290
Mailing Address - Fax:
Practice Address - Street 1:2817 NEW PINERY RD
Practice Address - Street 2:SUITE 103
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9240
Practice Address - Country:US
Practice Address - Phone:608-745-6290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28-039282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11009500Medicaid