Provider Demographics
NPI:1306205067
Name:ADVANCED LIVING CARE LLC
Entity Type:Organization
Organization Name:ADVANCED LIVING CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:YANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-505-2812
Mailing Address - Street 1:903 BONGEY DR
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-3780
Mailing Address - Country:US
Mailing Address - Phone:715-505-2812
Mailing Address - Fax:855-486-9323
Practice Address - Street 1:903 BONGEY DR
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-3780
Practice Address - Country:US
Practice Address - Phone:715-505-2812
Practice Address - Fax:855-486-9323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100027125Medicaid