Provider Demographics
NPI:1780103531
Name:TRI-STAR HOME CARE, LLC
Entity type:Organization
Organization Name:TRI-STAR HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KOUA
Authorized Official - Middle Name:F
Authorized Official - Last Name:THAO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-897-0050
Mailing Address - Street 1:4250 W FOND DU LAC AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-3564
Mailing Address - Country:US
Mailing Address - Phone:414-897-0050
Mailing Address - Fax:414-897-0052
Practice Address - Street 1:4250 W FOND DU LAC AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-3564
Practice Address - Country:US
Practice Address - Phone:414-897-0050
Practice Address - Fax:414-897-0052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI100034442253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100034442Medicaid