Provider Demographics
NPI:1669477659
Name:LJ III HEALTH MANAGEMENT INC.
Entity Type:Organization
Organization Name:LJ III HEALTH MANAGEMENT INC.
Other - Org Name:PREMIER REHABILITATION & SKILLED NURSING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-365-9526
Mailing Address - Street 1:2121 PIONEER DR
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-3025
Mailing Address - Country:US
Mailing Address - Phone:608-365-9526
Mailing Address - Fax:608-365-9761
Practice Address - Street 1:2121 PIONEER DR
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-3025
Practice Address - Country:US
Practice Address - Phone:608-365-9526
Practice Address - Fax:608-365-9761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3061314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20185800Medicaid
WI20185800Medicaid