Provider Demographics
NPI:1114548542
Name:ABBY'S CLUBHOUSE / ABBY BOO INC
Entity Type:Organization
Organization Name:ABBY'S CLUBHOUSE / ABBY BOO INC
Other - Org Name:MTC BUSINESS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAPRICE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-242-1174
Mailing Address - Street 1:PO BOX 1052
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53201-1052
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2640 W FONDULAC AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53206
Practice Address - Country:US
Practice Address - Phone:414-514-3651
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-27
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No251B00000XAgenciesCase Management
No251J00000XAgenciesNursing Care
No251K00000XAgenciesPublic Health or Welfare
No253Z00000XAgenciesIn Home Supportive Care