Provider Demographics
NPI:1609147958
Name:MED GROUP HOME HEALTH CARE AGENCY
Entity Type:Organization
Organization Name:MED GROUP HOME HEALTH CARE AGENCY
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:414-745-3146
Mailing Address - Street 1:2111 N DR MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-3101
Mailing Address - Country:US
Mailing Address - Phone:414-755-2103
Mailing Address - Fax:414-755-1784
Practice Address - Street 1:11402 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 214 B
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3447
Practice Address - Country:US
Practice Address - Phone:414-755-2009
Practice Address - Fax:414-755-1767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-18
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health