1144764127 NPI number — ADVANCING ABILITIES OF WISCONSIN, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144764127 NPI number — ADVANCING ABILITIES OF WISCONSIN, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCING ABILITIES OF WISCONSIN, LLC
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:
6
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:
1144764127
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10909 W GREENFIELD AVE
Provider Second Line Business Mailing Address:
SUITE 207
Provider Business Mailing Address City Name:
WEST ALLIS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53214-2379
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-259-0021
Provider Business Mailing Address Fax Number:
844-315-9207

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10909 W GREENFIELD AVE
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
WEST ALLIS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53214-2379
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-259-0021
Provider Business Practice Location Address Fax Number:
844-315-9207
Provider Enumeration Date:
12/12/2016

Additional Information

Authorized Official

Authorized Official Last Name:
GREENHAW
Authorized Official First Name:
RHONDA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT AND CHIEF CLINICAL OFFICE
Authorized Official Telephone Number:
414-259-0021

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  20-140 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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