Provider Demographics
NPI:1588839492
Name:SAN LUIS MEDICAL & REHAB CENTER
Entity Type:Organization
Organization Name:SAN LUIS MEDICAL & REHAB CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KNUDSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-494-5231
Mailing Address - Street 1:2305 SAN LUIS PL
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5211
Mailing Address - Country:US
Mailing Address - Phone:920-494-5231
Mailing Address - Fax:920-494-2855
Practice Address - Street 1:2305 SAN LUIS PL
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5211
Practice Address - Country:US
Practice Address - Phone:920-494-5231
Practice Address - Fax:920-494-2855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40275000Medicaid