Provider Demographics
NPI:1790963411
Name:LIFECARE HOSPITAL OF WISCONSIN
Entity Type:Organization
Organization Name:LIFECARE HOSPITAL OF WISCONSIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIETITIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTIE
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:SCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:RD, CD, CNSD
Authorized Official - Phone:262-524-2624
Mailing Address - Street 1:2400 GOLF RD
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-5590
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2400 GOLF RD
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-5590
Practice Address - Country:US
Practice Address - Phone:262-524-2624
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11023900Medicaid
WI11023900Medicaid