Provider Demographics
NPI:1144329004
Name:LSS OF MADISON LLC
Entity type:Organization
Organization Name:LSS OF MADISON LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:R
Authorized Official - Last Name:LUNDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-695-5618
Mailing Address - Street 1:110 BELMONT ROAD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53714-3129
Mailing Address - Country:US
Mailing Address - Phone:608-249-7391
Mailing Address - Fax:608-249-7906
Practice Address - Street 1:110 BELMONT ROAD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53714-3129
Practice Address - Country:US
Practice Address - Phone:608-249-7391
Practice Address - Fax:608-249-7906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3153314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20192700Medicaid
525074Medicare PIN