Provider Demographics
NPI:1417081415
Name:DEACONESS HOME HEALTH, INC.
Entity Type:Organization
Organization Name:DEACONESS HOME HEALTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:HERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-431-9760
Mailing Address - Street 1:2778 S 35TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3545
Mailing Address - Country:US
Mailing Address - Phone:414-431-9760
Mailing Address - Fax:414-431-9759
Practice Address - Street 1:2778 S 35TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3545
Practice Address - Country:US
Practice Address - Phone:414-431-9760
Practice Address - Fax:414-431-9759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1037251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41537800Medicaid
WI527288Medicare ID - Type UnspecifiedHHA