Provider Demographics
NPI:1871677963
Name:LINCOLN LUTHERAN COMMUNITY CARE CORPORATION
Entity Type:Organization
Organization Name:LINCOLN LUTHERAN COMMUNITY CARE CORPORATION
Other - Org Name:BECKER SHOOP CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:BOVA
Authorized Official - Suffix:JR
Authorized Official - Credentials:CPA
Authorized Official - Phone:262-898-2701
Mailing Address - Street 1:2000 DOMANIK DRIVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53404
Mailing Address - Country:US
Mailing Address - Phone:262-633-0500
Mailing Address - Fax:262-633-3045
Practice Address - Street 1:6101 16TH STREET
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406
Practice Address - Country:US
Practice Address - Phone:262-637-7486
Practice Address - Fax:262-633-3045
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LINCOLN LUTHERAN HOME OF RACINE INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-25
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3179314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20177300Medicaid
525669Medicare ID - Type Unspecified