1629137039 NPI number — SLEEP WELLNESS SOUTHSHORE, LLC

Table of content: (NPI 1629137039)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629137039 NPI number — SLEEP WELLNESS SOUTHSHORE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SLEEP WELLNESS SOUTHSHORE, 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:
1629137039
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2356 S 102ND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST ALLIS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53227-2104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-336-3000
Provider Business Mailing Address Fax Number:
414-336-1015

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 15TH AVE
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
SOUTH MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53172-1160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-336-3000
Provider Business Practice Location Address Fax Number:
414-336-1015
Provider Enumeration Date:
12/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BAAKE
Authorized Official First Name:
VERNON
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
414-336-3000

Provider Taxonomy Codes

  • Taxonomy code: 261QS1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1600270 . This is a "UNITED HEALTHCARE GROUP #" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 32890000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 391801802029 . This is a "ANTHEM BLUE CROSS GROUP #" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 391801802002 . This is a "TRICARE GROUP NUMBER" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 391801802029 . This is a "COMPCARE GROUP NUMBER" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 6758909 . This is a "CIGNA SERVICE LINE PIN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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