Provider Demographics
NPI:1336487347
Name:GRACE HOSPICE OF WISCONSIN, LLC
Entity Type:Organization
Organization Name:GRACE HOSPICE OF WISCONSIN, LLC
Other - Org Name:HARMONYCARES HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-824-6000
Mailing Address - Street 1:PO BOX 99278
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-9278
Mailing Address - Country:US
Mailing Address - Phone:248-824-6000
Mailing Address - Fax:855-618-6655
Practice Address - Street 1:2514 S 102ND ST STE 276
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2142
Practice Address - Country:US
Practice Address - Phone:414-395-8650
Practice Address - Fax:855-845-1846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-25
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI251G00000X, 251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1336487347Medicaid
WI2039OtherSTATE HOSPICE LICENSE