Provider Demographics
NPI:1225209703
Name:ST MARYS HOME HEALTH CARE OF WISCONSIN
Entity Type:Organization
Organization Name:ST MARYS HOME HEALTH CARE OF WISCONSIN
Other - Org Name:ST MARYS HOME HEALTH CARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:EVERETTE
Authorized Official - Suffix:
Authorized Official - Credentials:HOME CARE
Authorized Official - Phone:414-874-1733
Mailing Address - Street 1:4265 W FOND DU LAC AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-3527
Mailing Address - Country:US
Mailing Address - Phone:414-874-1733
Mailing Address - Fax:414-874-1737
Practice Address - Street 1:4265 W FOND DU LAC AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-3527
Practice Address - Country:US
Practice Address - Phone:414-874-1733
Practice Address - Fax:414-874-1737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1079251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health