1013248657 NPI number — FAITH HOPE & CHARITY FH&C SUPPORTIVE LIVING INC

Table of content: LUCILLE RENEE DEROSE PTA (NPI 1912025826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013248657 NPI number — FAITH HOPE & CHARITY FH&C SUPPORTIVE LIVING INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAITH HOPE & CHARITY FH&C SUPPORTIVE LIVING INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013248657
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3344 MARINA RD
Provider Second Line Business Mailing Address:
APARTMENT # 211
Provider Business Mailing Address City Name:
SOUTH MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53172-3961
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-793-4066
Provider Business Mailing Address Fax Number:
847-239-7694

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3344 MARINA RD
Provider Second Line Business Practice Location Address:
APARTMENT # 211
Provider Business Practice Location Address City Name:
SOUTH MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53172-3961
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-793-4066
Provider Business Practice Location Address Fax Number:
847-239-7694
Provider Enumeration Date:
01/21/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WRIGHT
Authorized Official First Name:
BETTY
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
414-793-4066

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X , with the licence number:  34233 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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