Provider Demographics
NPI:1619530474
Name:FIRSTLIGHT OF WEST BEND, WI
Entity Type:Organization
Organization Name:FIRSTLIGHT OF WEST BEND, WI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:GENGLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-979-5640
Mailing Address - Street 1:310 S MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:THERESA
Mailing Address - State:WI
Mailing Address - Zip Code:53091-9663
Mailing Address - Country:US
Mailing Address - Phone:920-276-2019
Mailing Address - Fax:
Practice Address - Street 1:W175N11163 STONEWOOD DR STE 208
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:WI
Practice Address - Zip Code:53022-6502
Practice Address - Country:US
Practice Address - Phone:262-299-5989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-17
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care