1780929075 NPI number — ELITE GARDEN HOMES, INC.

Table of content: (NPI 1780929075)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780929075 NPI number — ELITE GARDEN HOMES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELITE GARDEN HOMES, INC.
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:
1780929075
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10501 W BRADLEY RD
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:
53224-2673
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-459-3275
Provider Business Mailing Address Fax Number:
414-434-4207

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11414 W PARK PL
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53224-3500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-459-3275
Provider Business Practice Location Address Fax Number:
414-434-4207
Provider Enumeration Date:
11/28/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SONA
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
414-241-5019

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  1157 , 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: 1157 . This is a "WISCONSIN STATE HOME HEALTH LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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