Provider Demographics
NPI:1326221557
Name:TABOMA CORPORATION
Entity Type:Organization
Organization Name:TABOMA CORPORATION
Other - Org Name:BRIGHTSTAR HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:LOUKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-637-7767
Mailing Address - Street 1:4701 WASHINGTON AVE
Mailing Address - Street 2:SUITE 290
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4232
Mailing Address - Country:US
Mailing Address - Phone:262-637-7767
Mailing Address - Fax:262-637-7764
Practice Address - Street 1:4701 WASHINGTON AVE
Practice Address - Street 2:SUITE 290
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-4232
Practice Address - Country:US
Practice Address - Phone:262-637-7767
Practice Address - Fax:262-637-7764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1082251E00000X, 251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care