Healthcare Provider Details

I. General information

NPI: 1588080055
Provider Name (Legal Business Name): SAN LUIS HEALTH CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2014
Last Update Date: 12/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 SAN LUIS PL
GREEN BAY WI
54304-5211
US

IV. Provider business mailing address

2305 SAN LUIS PL
GREEN BAY WI
54304-5211
US

V. Phone/Fax

Practice location:
  • Phone: 920-494-5231
  • Fax: 920-494-1958
Mailing address:
  • Phone: 920-494-5231
  • Fax: 920-494-1958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateIA

VIII. Authorized Official

Name: JUDAH BIENSTOCK
Title or Position: MANAGING MEMBER
Credential:
Phone: 314-631-3000