Provider Demographics
NPI:1710119151
Name:LAKE VIEW ADULT FAMILY HOME
Entity Type:Organization
Organization Name:LAKE VIEW ADULT FAMILY HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED NURSE
Authorized Official - Prefix:MRS
Authorized Official - First Name:DOUANGMALA
Authorized Official - Middle Name:
Authorized Official - Last Name:PHRASAVATH
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:414-379-9713
Mailing Address - Street 1:W278N2456 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-5220
Mailing Address - Country:US
Mailing Address - Phone:414-379-9713
Mailing Address - Fax:
Practice Address - Street 1:W278N2456 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-5220
Practice Address - Country:US
Practice Address - Phone:414-379-9713
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-19
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty