Provider Demographics
NPI:1144293762
Name:ST MICHAEL'S EVANGELICAL LUTHERAN HOME FOR THE AGED
Entity type:Organization
Organization Name:ST MICHAEL'S EVANGELICAL LUTHERAN HOME FOR THE AGED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NURSING HOME ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:608-687-7721
Mailing Address - Street 1:270 NORTH STREET
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN CITY
Mailing Address - State:WI
Mailing Address - Zip Code:54629
Mailing Address - Country:US
Mailing Address - Phone:608-687-7721
Mailing Address - Fax:608-687-4006
Practice Address - Street 1:270 NORTH STREET
Practice Address - Street 2:
Practice Address - City:FOUNTAIN CITY
Practice Address - State:WI
Practice Address - Zip Code:54629
Practice Address - Country:US
Practice Address - Phone:608-687-7721
Practice Address - Fax:608-687-4006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20156400Medicaid
WI525610Medicare ID - Type Unspecified