Provider Demographics
NPI:1447223524
Name:WISCONSIN LUTHERAN CHILD & FAMILY SERVICES, INC
Entity Type:Organization
Organization Name:WISCONSIN LUTHERAN CHILD & FAMILY SERVICES, INC
Other - Org Name:WISCONSIN LUTHERAN CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:TANCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-353-5005
Mailing Address - Street 1:6800 N 76TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53223-5002
Mailing Address - Country:US
Mailing Address - Phone:414-353-5000
Mailing Address - Fax:414-353-5506
Practice Address - Street 1:6800 N 76TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-5002
Practice Address - Country:US
Practice Address - Phone:414-353-5000
Practice Address - Fax:414-353-5506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2179314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20132300Medicaid
WI71-00024OtherEVERCARE PROVIDER NUMBER
WI20132300Medicaid