Provider Demographics
NPI:1770758203
Name:HOUSE OF DAVID, INC.
Entity type:Organization
Organization Name:HOUSE OF DAVID, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:LURIDEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-444-3013
Mailing Address - Street 1:4417 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-1241
Mailing Address - Country:US
Mailing Address - Phone:414-444-3013
Mailing Address - Fax:
Practice Address - Street 1:4417 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-1241
Practice Address - Country:US
Practice Address - Phone:414-444-3013
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43086200Medicaid