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General NPI Number Information
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NPI Number | 1063238673
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Entity Type | Organization
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Legal Business Name | LAURAS HOME LLC
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Dates
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Enumeration Date | 11/27/2024
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Last Update Date | 11/27/2024
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Provider Practice Location Address
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Address Line | 945 LAKE GENEVA BLVD
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City | LAKE GENEVA
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State | WI
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Zip | 53147-2443
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Country | US
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Telephone | 262-903-2624
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 224
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City | LAKE GENEVA
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State | WI
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Zip | 53147-0224
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Country | US
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Telephone | 262-903-2624
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MARC KLUG
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Credential |
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Telephone | 262-903-2624
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State |
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