Provider Demographics
NPI:1003064064
Name:PRIMROSE RESIDENTIAL FACILITY
Entity Type:Organization
Organization Name:PRIMROSE RESIDENTIAL FACILITY
Other - Org Name:COMMUNITY BASED RESIDENTIAL FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:TEMPLE
Authorized Official - Last Name:GLADNEY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:414-445-3607
Mailing Address - Street 1:3910 W BURLEIGH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-1816
Mailing Address - Country:US
Mailing Address - Phone:414-445-3607
Mailing Address - Fax:414-445-4575
Practice Address - Street 1:3910 W BURLEIGH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1816
Practice Address - Country:US
Practice Address - Phone:414-445-3607
Practice Address - Fax:414-445-6575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health