Healthcare Provider Details

I. General information

NPI: 1700189602
Provider Name (Legal Business Name): DIVINE SAVIOR HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2010
Last Update Date: 12/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 NEW PINERY RD STE 103
PORTAGE WI
53901-9240
US

IV. Provider business mailing address

2817 NEW PINERY RD STE 103
PORTAGE WI
53901-9240
US

V. Phone/Fax

Practice location:
  • Phone: 608-745-6290
  • Fax:
Mailing address:
  • Phone: 608-745-6290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NR1301X
TaxonomyRural Acute Care Hospital
License Number28-039
License Number StateWI

VIII. Authorized Official

Name: KAYE PRIEVE
Title or Position: PATIENT FINCACIAL SUPERVISOR
Credential:
Phone: 608-745-5006