Provider Demographics
NPI:1801886239
Name:DIVINE SAVIOR HEALTHCARE, INC
Entity type:Organization
Organization Name:DIVINE SAVIOR HEALTHCARE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SVP & CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:YANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-847-2526
Mailing Address - Street 1:PO BOX 387
Mailing Address - Street 2:DIVINE SAVIOR HEALTHCARE EXTENDED CARE
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-0387
Mailing Address - Country:US
Mailing Address - Phone:608-742-4131
Mailing Address - Fax:608-745-5997
Practice Address - Street 1:2805 HUNTERS TRAIL
Practice Address - Street 2:DBA ASPIRUS TIVOLI COMMUNITY
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-0387
Practice Address - Country:US
Practice Address - Phone:608-742-4131
Practice Address - Fax:608-745-5997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2017314000000X
314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20135100Medicaid
WI52 5518Medicare ID - Type Unspecified