Provider Demographics
NPI:1649266404
Name:FOND DU LAC LUTHERAN HOME, INC.
Entity type:Organization
Organization Name:FOND DU LAC LUTHERAN HOME, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:MARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-261-0400
Mailing Address - Street 1:244 N MACY ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-3362
Mailing Address - Country:US
Mailing Address - Phone:920-951-9520
Mailing Address - Fax:920-921-0819
Practice Address - Street 1:244 N MACY ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-3362
Practice Address - Country:US
Practice Address - Phone:920-951-9520
Practice Address - Fax:920-921-0819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X
WI0047314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20129000Medicaid
WI20129000Medicaid