Basic Information
| Provider Information | |||||||||
| NPI: | 1427055920 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF OZAUKEE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LASATA CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | W76N677 WAUWATOSA RD | ||||||||
| Address2: | |||||||||
| City: | CEDARBURG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530121707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623775060 | ||||||||
| FaxNumber: | 2623774203 | ||||||||
| Practice Location | |||||||||
| Address1: | W76 N677 WAUWATOSA RD | ||||||||
| Address2: | |||||||||
| City: | CEDARBURG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530121707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625122844 | ||||||||
| FaxNumber: | 2623774202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 08/06/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LUEDTKE | ||||||||
| AuthorizedOfficialFirstName: | RALPH | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | NH ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2625122844 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | NH ADMINISTRATOR | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 2361 | WI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 20129900 | 05 | WI | MEDICAID |