1265040711 NPI number — DIVERSITY HOME HEALTH SERVICES

Table of content: (NPI 1265040711)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265040711 NPI number — DIVERSITY HOME HEALTH SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIVERSITY HOME HEALTH SERVICES
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:
1265040711
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2455 S HOWELL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53207-1638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-810-4675
Provider Business Mailing Address Fax Number:
414-885-0877

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2455 S HOWELL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53207-1638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-810-4675
Provider Business Practice Location Address Fax Number:
414-885-0877
Provider Enumeration Date:
07/21/2020

Additional Information

Authorized Official

Authorized Official Last Name:
RODRIGUEZ
Authorized Official First Name:
EVARISTO
Authorized Official Middle Name:
ANTONIO
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
414-422-5317

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 347C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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