Provider Demographics
NPI:1740545730
Name:DIVINE SAVIOR HEALTHCARE
Entity type:Organization
Organization Name:DIVINE SAVIOR HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COTA
Authorized Official - Prefix:MISS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:ASSOCIATE DEGREE
Authorized Official - Phone:608-745-4131
Mailing Address - Street 1:W6412 MILITARY RD
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:WI
Mailing Address - Zip Code:53926-9330
Mailing Address - Country:US
Mailing Address - Phone:608-408-8692
Mailing Address - Fax:
Practice Address - Street 1:W6412 MILITARY RD
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:WI
Practice Address - Zip Code:53926-9330
Practice Address - Country:US
Practice Address - Phone:608-408-8692
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-06
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4718-27282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural