Provider Demographics
NPI:1669910469
Name:DIMERA HOUSE
Entity type:Organization
Organization Name:DIMERA HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:CRROLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-551-3489
Mailing Address - Street 1:4002 WEST FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209
Mailing Address - Country:UM
Mailing Address - Phone:414-551-3489
Mailing Address - Fax:
Practice Address - Street 1:4002 W FAIROUNT AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209
Practice Address - Country:US
Practice Address - Phone:414-551-3489
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-01
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care