Provider Demographics
NPI:1295103463
Name:LIFE ENHANCEMENT SUPPORTIVE SERVICES COMMUNITY ASSISTANCE
Entity type:Organization
Organization Name:LIFE ENHANCEMENT SUPPORTIVE SERVICES COMMUNITY ASSISTANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TONYETTA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:414-690-0672
Mailing Address - Street 1:6001 W CENTER ST
Mailing Address - Street 2:201
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-2154
Mailing Address - Country:US
Mailing Address - Phone:414-690-0672
Mailing Address - Fax:
Practice Address - Street 1:6001 W CENTER ST
Practice Address - Street 2:201
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-2154
Practice Address - Country:US
Practice Address - Phone:414-690-0672
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-04
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1184060998Medicaid