Provider Demographics
NPI:1730643107
Name:DIVINE REHABILITATION AND NURSING AT ST CROIX LLC
Entity Type:Organization
Organization Name:DIVINE REHABILITATION AND NURSING AT ST CROIX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ISAAK
Authorized Official - Middle Name:
Authorized Official - Last Name:MARKOVITS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-753-0250
Mailing Address - Street 1:1632 61ST ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-2109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 E LOUISIANA ST
Practice Address - Street 2:
Practice Address - City:SAINT CROIX FALLS
Practice Address - State:WI
Practice Address - Zip Code:54024-9501
Practice Address - Country:US
Practice Address - Phone:715-483-9815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-30
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20157500Medicaid