Provider Demographics
NPI:1942605670
Name:METHU ADULT FAMILY CARE HOME II
Entity Type:Organization
Organization Name:METHU ADULT FAMILY CARE HOME II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MWANGI
Authorized Official - Last Name:METHU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-466-8930
Mailing Address - Street 1:3070 N 55TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-1563
Mailing Address - Country:US
Mailing Address - Phone:414-466-8930
Mailing Address - Fax:414-873-4501
Practice Address - Street 1:2824 N 59TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1504
Practice Address - Country:US
Practice Address - Phone:414-466-8930
Practice Address - Fax:414-873-4501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0015250320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0015250OtherSTATE OF WISCONSIN