Provider Demographics
NPI:1538124169
Name:DIVINE SAVIOR HEALTHCARE INC
Entity type:Organization
Organization Name:DIVINE SAVIOR HEALTHCARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SVP & CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:YANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-847-2526
Mailing Address - Street 1:29980 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1299
Mailing Address - Country:US
Mailing Address - Phone:715-847-2304
Mailing Address - Fax:715-843-1188
Practice Address - Street 1:2817 NEW PINERY ROAD
Practice Address - Street 2:DIVINE SAVIOR HEALTHCARE INC
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-0387
Practice Address - Country:US
Practice Address - Phone:608-742-4131
Practice Address - Fax:608-742-6098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI328251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41533500Medicaid
WI41533500Medicaid