Provider Demographics
NPI:1821670118
Name:HEIZER, LLC
Entity Type:Organization
Organization Name:HEIZER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TEKEYA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-698-8782
Mailing Address - Street 1:PO BOX 18115
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-0115
Mailing Address - Country:US
Mailing Address - Phone:414-698-8782
Mailing Address - Fax:
Practice Address - Street 1:9708 W THURSTON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53225-2527
Practice Address - Country:US
Practice Address - Phone:414-935-2732
Practice Address - Fax:414-831-9978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100161598Medicaid