Provider Demographics
NPI:1013275775
Name:DESTANI'S CHILD MEDICAL DAY CARE PROVIDER, INC
Entity Type:Organization
Organization Name:DESTANI'S CHILD MEDICAL DAY CARE PROVIDER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:M
Authorized Official - Last Name:GORDEN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:414-217-2495
Mailing Address - Street 1:3062 N 58TH ST
Mailing Address - Street 2:#1
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-1545
Mailing Address - Country:US
Mailing Address - Phone:414-217-2495
Mailing Address - Fax:414-445-3893
Practice Address - Street 1:3062 N 58TH ST
Practice Address - Street 2:#1
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1545
Practice Address - Country:US
Practice Address - Phone:414-217-2495
Practice Address - Fax:414-445-3893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric