Provider Demographics
NPI:1801898127
Name:PROMINENT HEALTH CARE INC
Entity type:Organization
Organization Name:PROMINENT HEALTH CARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:NAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-351-0543
Mailing Address - Street 1:6263 N GREEN BAY AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-3823
Mailing Address - Country:US
Mailing Address - Phone:414-351-0543
Mailing Address - Fax:414-351-7977
Practice Address - Street 1:6263 N GREEN BAY AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53209-3823
Practice Address - Country:US
Practice Address - Phone:414-351-0543
Practice Address - Fax:414-351-7977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3218314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20190700Medicaid
WI20190700Medicaid