Provider Demographics
NPI:1922572312
Name:WALTER'S SECOND CHANCE OF MILWAUKEE, LLC.
Entity Type:Organization
Organization Name:WALTER'S SECOND CHANCE OF MILWAUKEE, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-388-3518
Mailing Address - Street 1:3043 N. 29TH STREET
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3043 N. 29TH STREET
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210
Practice Address - Country:US
Practice Address - Phone:414-388-3815
Practice Address - Fax:414-359-2316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care