Provider Demographics
NPI:1891986964
Name:GL HEALTHCARE
Entity Type:Organization
Organization Name:GL HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ILENE
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:608-223-1452
Mailing Address - Street 1:2620 WAUNONA WAY
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-1525
Mailing Address - Country:US
Mailing Address - Phone:608-223-1452
Mailing Address - Fax:
Practice Address - Street 1:470 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:WI
Practice Address - Zip Code:53536-1014
Practice Address - Country:US
Practice Address - Phone:608-882-6557
Practice Address - Fax:608-882-6559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI963-019314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1205880879Medicare PIN