Provider Demographics
NPI:1356316160
Name:PROHEALTH HOME CARE, INC.
Entity Type:Organization
Organization Name:PROHEALTH HOME CARE, INC.
Other - Org Name:PROHEALTH HOME HOSPICE AND ANGELSGRACE HOSPICE
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR, PROHEALTH HOME CARE, INC.
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MBA
Authorized Official - Phone:262-928-7887
Mailing Address - Street 1:1020 JAMES DR
Mailing Address - Street 2:STE E
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029
Mailing Address - Country:US
Mailing Address - Phone:262-928-7444
Mailing Address - Fax:262-928-7446
Practice Address - Street 1:1020 JAMES DR
Practice Address - Street 2:STE E
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029
Practice Address - Country:US
Practice Address - Phone:262-928-7444
Practice Address - Fax:262-928-7446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI527251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI7200001OtherUNITED HEALTH CARE
WI43183600Medicaid
WI43183600Medicaid