Provider Demographics
NPI:1245781418
Name:DYCORA TRANSITIONAL HEALTH - MILWAUKEE LLC
Entity Type:Organization
Organization Name:DYCORA TRANSITIONAL HEALTH - MILWAUKEE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-228-8700
Mailing Address - Street 1:1616 W BENDER RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-3802
Mailing Address - Country:US
Mailing Address - Phone:414-228-8700
Mailing Address - Fax:
Practice Address - Street 1:1616 W BENDER RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53209-3802
Practice Address - Country:US
Practice Address - Phone:414-228-8700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-21
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3178314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI525309Medicare Oscar/Certification