Provider Demographics
NPI:1508852708
Name:LUTHERAN HOMES OF OCONOMOWOC INC.
Entity Type:Organization
Organization Name:LUTHERAN HOMES OF OCONOMOWOC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BIRR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-560-6969
Mailing Address - Street 1:PO BOX 208
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-0208
Mailing Address - Country:US
Mailing Address - Phone:262-560-6964
Mailing Address - Fax:262-567-7189
Practice Address - Street 1:1305 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-2646
Practice Address - Country:US
Practice Address - Phone:262-560-6964
Practice Address - Fax:262-567-7189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20152300Medicaid
WI20152300Medicaid