Provider Demographics
NPI:1376546762
Name:AMERICAN LUTHERAN CHURCH-NORTHLAND LUTHERN SERVICES FOR THE ELDERLY, I
Entity Type:Organization
Organization Name:AMERICAN LUTHERAN CHURCH-NORTHLAND LUTHERN SERVICES FOR THE ELDERLY, I
Other - Org Name:LUTHER HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:MR
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 1:831 PINE BEACH RD
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-4225
Mailing Address - Country:US
Mailing Address - Phone:715-732-0155
Mailing Address - Fax:715-732-5595
Practice Address - Street 1:831 PINE BEACH RD
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-4225
Practice Address - Country:US
Practice Address - Phone:715-732-0155
Practice Address - Fax:715-732-5899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2155314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20126700Medicaid
WI20126700Medicaid