Provider Demographics
NPI:1841667466
Name:ST. ANN CENTER FOR INTERGENERATIONAL CARE
Entity type:Organization
Organization Name:ST. ANN CENTER FOR INTERGENERATIONAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR DENTAL PROGRAMS
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:K
Authorized Official - Last Name:CHEREKLAABS
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:414-977-5000
Mailing Address - Street 1:2801 E MORGAN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-3771
Mailing Address - Country:US
Mailing Address - Phone:414-977-5000
Mailing Address - Fax:
Practice Address - Street 1:2450 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53205
Practice Address - Country:US
Practice Address - Phone:414-977-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-31
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5705-16251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1982075719Medicaid
WI1831499532Medicaid
WI1023140118Medicaid