Provider Demographics
NPI:1235814757
Name:TEAM SELFKINGDOM
Entity Type:Organization
Organization Name:TEAM SELFKINGDOM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SELFKINGDOM
Authorized Official - Middle Name:
Authorized Official - Last Name:ISALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-671-9045
Mailing Address - Street 1:3025 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53206-3209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1930 W NASH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53206-2417
Practice Address - Country:US
Practice Address - Phone:312-546-4966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-21
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No332U00000XSuppliersHome Delivered Meals
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100244229Medicaid