Healthcare Provider Details

I. General information

NPI: 1124083894
Provider Name (Legal Business Name): DIVINE SAVIOR HEALTHCARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 NEW PINERY RD
PORTAGE WI
53901-9240
US

IV. Provider business mailing address

29980 NETWORK PL
CHICAGO IL
60673-1299
US

V. Phone/Fax

Practice location:
  • Phone: 608-742-4131
  • Fax: 608-742-6098
Mailing address:
  • Phone: 608-742-4131
  • Fax: 608-742-6098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number3729800
License Number StateWI
# 5
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: MRS. LORI PECK
Title or Position: SVP- CHIEF FINANCIAL OFFICER
Credential:
Phone: 715-847-2575