Healthcare Provider Details

I. General information

NPI: 1053291476
Provider Name (Legal Business Name): LAKE MILLS AL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2025
Last Update Date: 09/05/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 ONEIL ST
LAKE MILLS WI
53551-1365
US

IV. Provider business mailing address

600 3RD AVE FL 21
NEW YORK NY
10016-1916
US

V. Phone/Fax

Practice location:
  • Phone: 877-295-3747
  • Fax:
Mailing address:
  • Phone: 646-314-4327
  • Fax:

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: DIANE GABRIELE LIMBURG
Title or Position: LICENSING PROJECT COORDINATOR
Credential:
Phone: 951-552-0109