Healthcare Provider Details

I. General information

NPI: 1548192214
Provider Name (Legal Business Name): FOND DU LAC LUTHERAN HOME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 N MACY ST
FOND DU LAC WI
54935-3362
US

IV. Provider business mailing address

1045 HILL ST
WATERTOWN WI
53098-3001
US

V. Phone/Fax

Practice location:
  • Phone: 920-921-9520
  • Fax: 920-921-0819
Mailing address:
  • Phone: 920-921-9520
  • Fax: 920-921-0819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: JULIE ANNE MARKS
Title or Position: CFO
Credential:
Phone: 920-261-0400