NPIMap

Organization Active NPI

Great Lakes Healthcare, Inc.

Doing business as Preceptor Hospice

  • Community Based Hospice Care Agency
  • Germantown, WI
National Provider Identifier
1619532132
Registry record updated Aug 11, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community Based Hospice Care AgencyTaxonomy code 251G00000X
Legal business name
GREAT LAKES HEALTHCARE, INC.
Doing business as
Preceptor Hospice
Practice address
W175N11117 Stonewood Dr Ste 100
Germantown, WI 53022
Phone
(262) 293-3951
NPI assigned
May 9, 2019
Last updated
Aug 11, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 11, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Lee Johnson
Title
Treasurer
Phone
(208) 401-1369

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community Based Hospice Care Agency 251G00000X Primary

Addresses

Primary practice location

W175N11117 Stonewood Dr Ste 100
Germantown, WI 53022

Mailing address

W175N11117 Stonewood Dr Ste 100
Germantown, WI 53022-6505
Phone (262) 293-3951

Other practice location 1

20875 Crossroads Cir Ste 850
Waukesha, WI 53186-4093
Phone (262) 290-4590

Other practice location 2

1211 Rickmeyer Dr Ste A
Fond Du Lac, WI 54937-2214
Phone (920) 827-4555

Other practice location 3

446 N Westhill Blvd Ste D
Appleton, WI 54914-6532
Phone (920) 797-4497

Other names 1

  • Preceptor Hospice Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20190622000052 WI Part A Provider - Hospice 5395079719 Practice locations: Appleton, WI; Fond Du Lac, WI; Germantown, WI; Sheboygan, WI; Waukesha, WI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1619532132. Details of each certification follow.

Hospice certification: CCN 521593

Legal name
GREAT LAKES HEALTHCARE INC
Doing business as
PRECEPTOR HOSPICE
Certification status
Active
Provider type (POS)
Hospice
Participating since
Sep 27, 2012
Last certification
Sep 27, 2012
Ownership / control type
Proprietary - Other
Organization structure
CorporationProprietary
Incorporated
Mar 26, 2019 in NV
Enrollment address
W175N11117 Stonewood Dr
Ste 100
Germantown, WI 53022-6505

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Care Compare: Hospice

Medicare Care Compare
Listed as
Preceptor HospiceCCN 521593 · All quality measures
Ownership
For-Profit
Certified
Sep 27, 2012
Medicare certification status
ActiveFrom the Provider of Services file

National Provider Directory

National Provider Directory
Tax ID family
Great Lakes Healthcare Inc3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Locations

446 N Westhill Blvd
Ste D
Appleton, WI 54914
Phone (920) 797-4497

20875 Crossroads Cir
Ste 850
Waukesha, WI 53186
Phone (262) 290-4590

Ownership & related parties

All disclosed owners & managing parties 8

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Cornerstone Healthcare Inc Organization, Eagle, ID Corporation, For-profit 5% Or Greater Direct Ownership Interest Jun 1, 2019 100%
Brent Guerisoli Individual Corporate Director Mar 5, 2023
Lee Johnson Individual Corporate OfficerTreasurer Jun 1, 2019
The Pennant Group Inc Organization, Eagle, ID Corporation, For-profit 5% Or Greater Indirect Ownership Interest Oct 1, 2019 100%
Rich Firth Individual W-2 Managing EmployeeAdministrator Oct 15, 2022
John J Gochnour Individual Corporate OfficerPresident Jan 19, 2024
Brian Wolter Individual Contracted Managing EmployeeMD; May 3, 2023
Elliot McMillan Individual Corporate OfficerSecretary Jun 1, 2019

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 141

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 141

Change-of-ownership history 1

DateEventCounterparty
Jun 1, 2019 Change of OwnershipThis provider was the buyer Serenity Hospice Care LLCCCN 521593, WI, NPI 1992076608

Change of ownership 1

Medicare changes of ownership in which this facility was the buyer or the seller.

Practitioners & affiliated clinicians

Affiliated clinicians 5

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1557360000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1691712000000",
    "number": "1619532132",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "W175N11117 STONEWOOD DR STE 100",
            "city": "GERMANTOWN",
            "state": "WI",
            "postal_code": "530226505",
            "telephone_number": "262-293-3951"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "W175N11117 STONEWOOD DR STE 100",
            "city": "GERMANTOWN",
            "state": "WI",
            "postal_code": "53022",
            "telephone_number": "262-293-3951"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "20875 Crossroads Cir Ste 850",
            "address_purpose": "LOCATION",
            "city": "Waukesha",
            "state": "WI",
            "postal_code": "531864093",
            "country_code": "US",
            "telephone_number": "262-290-4590",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1211 Rickmeyer Dr Ste A",
            "address_purpose": "LOCATION",
            "city": "Fond Du Lac",
            "state": "WI",
            "postal_code": "549372214",
            "country_code": "US",
            "telephone_number": "920-827-4555",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "446 N Westhill Blvd Ste D",
            "address_purpose": "LOCATION",
            "city": "Appleton",
            "state": "WI",
            "postal_code": "549146532",
            "country_code": "US",
            "telephone_number": "920-797-4497",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "GREAT LAKES HEALTHCARE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-05-09",
        "last_updated": "2023-08-11",
        "certification_date": "2023-08-11",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "LEE",
        "authorized_official_title_or_position": "TREASURER",
        "authorized_official_telephone_number": "208-401-1369"
    },
    "taxonomies": [
        {
            "code": "251G00000X",
            "taxonomy_group": "",
            "desc": "Hospice Care, Community Based",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Preceptor Hospice",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Germantown, WI

Sources for this page

Verify at the official NPI Registry.