Provider Demographics
NPI:1306398110
Name:MED GROUP HOME HEALTH CARE AGENCY LLC
Entity Type:Organization
Organization Name:MED GROUP HOME HEALTH CARE AGENCY LLC
Other - Org Name:MED GROUP HOME HEALTH CARE AGENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARIKO
Authorized Official - Middle Name:
Authorized Official - Last Name:MEKVABISHVILI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-755-2103
Mailing Address - Street 1:11053 N TOWNE SQUARE RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5051
Mailing Address - Country:US
Mailing Address - Phone:414-755-2103
Mailing Address - Fax:414-755-1784
Practice Address - Street 1:11053 N TOWNE SQUARE RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5051
Practice Address - Country:US
Practice Address - Phone:414-755-2103
Practice Address - Fax:414-755-1784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1194251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health