1225783913 NPI number — DIVERSIFIED HEALTH AND SUPPORTIVE SERVICES LLC

Table of content: (NPI 1225783913)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225783913 NPI number — DIVERSIFIED HEALTH AND SUPPORTIVE SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIVERSIFIED HEALTH AND SUPPORTIVE SERVICES 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:
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:
1225783913
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2903 N 74TH ST APT 1
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:
53210-1000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-651-5954
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11520 N PORT WASHINGTON RD STE 208
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEQUON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53092-3432
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-651-5954
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/21/2022

Additional Information

Authorized Official

Authorized Official Last Name:
PETTIS
Authorized Official First Name:
SHAUNA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/SUBADMINISTRATOR
Authorized Official Telephone Number:
414-748-7776

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com