Provider Demographics
NPI:1861904294
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:VP REVENUE CYCLE
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:PECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-847-2988
Mailing Address - Street 1:2817 NEW PINERY ROAD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-0387
Mailing Address - Country:US
Mailing Address - Phone:608-745-0560
Mailing Address - Fax:608-742-6098
Practice Address - Street 1:102 GILLETTE STREET
Practice Address - Street 2:
Practice Address - City:PARDEEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53954
Practice Address - Country:US
Practice Address - Phone:608-429-2185
Practice Address - Fax:608-429-3966
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVINE SAVIOR HEALTHCARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-25
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32850500Medicaid