Provider Demographics
NPI:1700335270
Name:PETRA'S LIVING ASSISTANCE, LLC
Entity Type:Organization
Organization Name:PETRA'S LIVING ASSISTANCE, LLC
Other - Org Name:VISITING ANGELS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:STOLLENWERK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-695-4418
Mailing Address - Street 1:347 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-3413
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:347 PARK AVE
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3413
Practice Address - Country:US
Practice Address - Phone:262-695-4418
Practice Address - Fax:262-695-7461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care