Provider Demographics
NPI:1548259807
Name:ST. FRANCIS HOME OF FOND DU LAC WISCONSIN, INC
Entity type:Organization
Organization Name:ST. FRANCIS HOME OF FOND DU LAC WISCONSIN, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:TROST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-926-6068
Mailing Address - Street 1:33 EVERETT ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4318
Mailing Address - Country:US
Mailing Address - Phone:920-923-7980
Mailing Address - Fax:920-923-7995
Practice Address - Street 1:33 EVERETT ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935
Practice Address - Country:US
Practice Address - Phone:920-926-7980
Practice Address - Fax:920-923-7995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-19
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10373310400000X
WI2561314000000X, 313M00000X
WI313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20158100Medicaid
WI525595Medicare UPIN