Healthcare Provider Details

I. General information

NPI: 1376546762
Provider Name (Legal Business Name): AMERICAN LUTHERAN CHURCH-NORTHLAND LUTHERN SERVICES FOR THE ELDERLY, I
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 08/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 PINE BEACH RD
MARINETTE WI
54143-4225
US

IV. Provider business mailing address

831 PINE BEACH RD
MARINETTE WI
54143-4225
US

V. Phone/Fax

Practice location:
  • Phone: 715-732-0155
  • Fax: 715-732-5899
Mailing address:
  • Phone: 715-732-0155
  • Fax: 715-732-5595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2155
License Number StateWI

VIII. Authorized Official

Name: MR. GARY GUSTAFSON
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 715-732-0155