Provider Demographics
NPI:1235356924
Name:CAREAVAN, INC. OF WISCONSIN
Entity Type:Organization
Organization Name:CAREAVAN, INC. OF WISCONSIN
Other - Org Name:CAREAVAN, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:LICARY
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, RT(R)
Authorized Official - Phone:815-633-8461
Mailing Address - Street 1:7117 CLINTON RD
Mailing Address - Street 2:SUITE NO. 3
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-3804
Mailing Address - Country:US
Mailing Address - Phone:815-633-8461
Mailing Address - Fax:815-633-8486
Practice Address - Street 1:7117 CLINTON ROAD
Practice Address - Street 2:SUITE NO. 3
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-3804
Practice Address - Country:US
Practice Address - Phone:815-633-8461
Practice Address - Fax:815-633-8486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered343800000XTransportation ServicesSecured Medical Transport (VAN)
Not Answered343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41464300Medicaid
IL=========001Medicaid