1366794562 NPI number — MILWAUKEE HEALTH CARE, LLC

Table of content: (NPI 1366794562)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366794562 NPI number — MILWAUKEE HEALTH CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILWAUKEE HEALTH CARE, 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:
WELLSPRING OF MILWAUKEE
Provider Other Organization Name Type Code:
3
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:
1366794562
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 BOURBON ST
Provider Second Line Business Mailing Address:
WEST PEABODY EXECUTIVE CENTER, SUITE 200
Provider Business Mailing Address City Name:
PEABODY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01960-1384
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-535-6700
Provider Business Mailing Address Fax Number:
978-535-6701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9350 W FOND DU LAC 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:
53225-1714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-438-4360
Provider Business Practice Location Address Fax Number:
414-464-3622
Provider Enumeration Date:
10/11/2012

Additional Information

Authorized Official

Authorized Official Last Name:
NICHOLSON
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
978-535-6700

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  2821 , 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)

  • Identifier: 52-5367 . This is a "MEDICARE PROVIDER NUMBER" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 100033186 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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