Provider Demographics
NPI:1477660132
Name:MID AMERICA HEALTHCARE CORP OF WISCONSIN
Entity Type:Organization
Organization Name:MID AMERICA HEALTHCARE CORP OF WISCONSIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/ DON
Authorized Official - Prefix:MS
Authorized Official - First Name:SOUPHALACK
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAMMYVONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-578-2961
Mailing Address - Street 1:811 N HAWLEY RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53213-3289
Mailing Address - Country:US
Mailing Address - Phone:414-578-2961
Mailing Address - Fax:414-578-2962
Practice Address - Street 1:811 N HAWLEY RD
Practice Address - Street 2:STE 201
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53213-3289
Practice Address - Country:US
Practice Address - Phone:414-578-2961
Practice Address - Fax:414-578-2962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI527256251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43107100Medicaid
WI527256Medicare Oscar/Certification