Provider Demographics
NPI:1598539231
Name:FOFUELAKA, FOLEFAC
Entity Type:Individual
Prefix:
First Name:FOLEFAC
Middle Name:
Last Name:FOFUELAKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 ROBIN DR
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-3330
Mailing Address - Country:US
Mailing Address - Phone:240-701-6013
Mailing Address - Fax:
Practice Address - Street 1:860 ROBIN DR
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-3330
Practice Address - Country:US
Practice Address - Phone:240-701-6013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0019574311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home