MEDICARE: DIVINE SAVIOR HEALTHCARE, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
2	314000000X	Skilled Nursing Facility	2017	WI
3	314000000X	Skilled Nursing Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801886239
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE SAVIOR HEALTHCARE, INC

Provider Business Mailing Address
First Line	:	29980 NETWORK PL
Second Line	:	DIVINE SAVIOR HEALTHCARE EXTENDED CARE
City	:	CHICAGO
State	:	IL
Zip	:	60673-1299
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2805 HUNTERS TRAIL
Second Line	:	DBA ASPIRUS TIVOLI COMMUNITY
City	:	PORTAGE
State	:	WI
Zip	:	53901-0387
Country	:	US
Telephone Number	:	608-742-4131
Fax Number	:	608-745-5997

Authorized Official
Title or Position	:	SVP & CHIEF FINANCIAL OFFICER
Name	:	MRS. JERRY M YANG
Credential	:
Telephone Number	:	715-847-2526

Provider Enumeration Date	:	10/26/2005
Last Update Date	:	10/23/2025

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Directions to “DIVINE SAVIOR HEALTHCARE, INC ” Practice Location

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