Provider Demographics
NPI: | 1003670977 |
---|---|
Name: | HOUSE OF SIRENITY LLC |
Entity Type: | Organization |
Organization Name: | HOUSE OF SIRENITY LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PROGRAM DIRECTOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | DESSA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BEARDEN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 262-221-8524 |
Mailing Address - Street 1: | 2823 N 36TH ST |
Mailing Address - Street 2: | |
Mailing Address - City: | MILWAUKEE |
Mailing Address - State: | WI |
Mailing Address - Zip Code: | 53210-1925 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 414-485-7207 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2823 N 36TH ST |
Practice Address - Street 2: | |
Practice Address - City: | MILWAUKEE |
Practice Address - State: | WI |
Practice Address - Zip Code: | 53210-1925 |
Practice Address - Country: | US |
Practice Address - Phone: | 414-485-7207 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2024-02-09 |
Last Update Date: | 2024-02-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 3104A0630X | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Behavioral Disturbances |
No | 310400000X | Nursing & Custodial Care Facilities | Assisted Living Facility |