Provider Demographics
NPI:1740716729
Name:SUPPORTIVE LIVING HOME HEALTH CARE
Entity type:Organization
Organization Name:SUPPORTIVE LIVING HOME HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:414-484-6037
Mailing Address - Street 1:6815 W CAPITOL DR
Mailing Address - Street 2:SUITE 212
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-2070
Mailing Address - Country:US
Mailing Address - Phone:414-484-6037
Mailing Address - Fax:414-755-7450
Practice Address - Street 1:6815 W CAPITOL DR
Practice Address - Street 2:SUITE 212
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2070
Practice Address - Country:US
Practice Address - Phone:414-484-6037
Practice Address - Fax:414-755-7450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100042529Medicaid