Provider Demographics
NPI:1811517642
Name:LARSON HOUSE PLATINUM LLC
Entity type:Organization
Organization Name:LARSON HOUSE PLATINUM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:TERESINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-940-6608
Mailing Address - Street 1:2448 S 102ND ST STE 305
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2141
Mailing Address - Country:US
Mailing Address - Phone:414-940-6608
Mailing Address - Fax:
Practice Address - Street 1:550 RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-1721
Practice Address - Country:US
Practice Address - Phone:920-623-5253
Practice Address - Fax:920-623-5255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-22
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0016818OtherWISCNSIN DHS
WI0015679OtherWISCONSIN DHS