Provider Demographics
NPI:1174017339
Name:NORTH LAKES NURSING HOME HEALTH CARE AGENCY LLC
Entity Type:Organization
Organization Name:NORTH LAKES NURSING HOME HEALTH CARE AGENCY LLC
Other - Org Name:NORTH LAKES NURSING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-825-3204
Mailing Address - Street 1:225 E FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-5853
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 E FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217
Practice Address - Country:US
Practice Address - Phone:414-967-9355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-20
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health