Provider Demographics
NPI:1437538642
Name:TRI-STAR RESIDENCE, LLC
Entity Type:Organization
Organization Name:TRI-STAR RESIDENCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KOUA
Authorized Official - Middle Name:F
Authorized Official - Last Name:THAO
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:414-248-9239
Mailing Address - Street 1:7504 W RUBY AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-5458
Mailing Address - Country:US
Mailing Address - Phone:414-248-9239
Mailing Address - Fax:
Practice Address - Street 1:7504 W RUBY AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-5458
Practice Address - Country:US
Practice Address - Phone:414-248-9239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100014873Medicaid