Provider Demographics
NPI:1629079132
Name:ST ANN CENTER FOR INTERGENERATIONAL CARE INC
Entity Type:Organization
Organization Name:ST ANN CENTER FOR INTERGENERATIONAL CARE INC
Other - Org Name:ST. ANN CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDNA
Authorized Official - Middle Name:
Authorized Official - Last Name:LONERGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-977-5000
Mailing Address - Street 1:2801 E MORGAN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-3771
Mailing Address - Country:US
Mailing Address - Phone:414-977-5000
Mailing Address - Fax:
Practice Address - Street 1:2801 E MORGAN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-3771
Practice Address - Country:US
Practice Address - Phone:414-977-5000
Practice Address - Fax:414-977-5050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7033-031164W00000X
WI685-026225X00000X
261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41812200Medicaid
WI41812200Medicaid