Provider Demographics
NPI:1437409737
Name:MED GROUP ADULT DAY CARE OF WI, LLC
Entity Type:Organization
Organization Name:MED GROUP ADULT DAY CARE OF WI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
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:414-755-0558
Mailing Address - Street 1:10549 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130-2057
Mailing Address - Country:US
Mailing Address - Phone:414-755-0558
Mailing Address - Fax:414-755-2470
Practice Address - Street 1:10549 W FOREST HOME AVE
Practice Address - Street 2:
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130-2057
Practice Address - Country:US
Practice Address - Phone:414-755-0558
Practice Address - Fax:414-755-2470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility