1154750511 NPI number — MED GROUP ADULT DAY CARE OF WI

Table of content: (NPI 1154750511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154750511 NPI number — MED GROUP ADULT DAY CARE OF WI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MED GROUP ADULT DAY CARE OF WI
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:
1154750511
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11402 N PORT WASHINGTON RD
Provider Second Line Business Mailing Address:
SUITE 215
Provider Business Mailing Address City Name:
MEQUON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53092-3447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-755-0558
Provider Business Mailing Address Fax Number:
414-755-1763

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6572 S LOVERS LANE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRANKLIN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53132-1209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-755-0558
Provider Business Practice Location Address Fax Number:
414-755-2470
Provider Enumeration Date:
11/06/2013

Additional Information

Authorized Official

Authorized Official Last Name:
MEKVABISHVILI
Authorized Official First Name:
DARIKO
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
414-755-0558

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X , with the licence number:  0014565 , 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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