Provider Demographics
NPI:1669648242
Name:KENOSHA AREA FAMILY AND AGING SERVICES, INC.
Entity Type:Organization
Organization Name:KENOSHA AREA FAMILY AND AGING SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:G
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-658-3508
Mailing Address - Street 1:7730 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-1518
Mailing Address - Country:US
Mailing Address - Phone:262-658-3508
Mailing Address - Fax:262-658-2263
Practice Address - Street 1:7730 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-1518
Practice Address - Country:US
Practice Address - Phone:262-658-3508
Practice Address - Fax:262-658-2263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44007400Medicaid