Provider Demographics
NPI:1912157223
Name:SUPPORTIVE HOME LIVING SERVICES, INC.
Entity Type:Organization
Organization Name:SUPPORTIVE HOME LIVING SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:KINGSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-544-0687
Mailing Address - Street 1:250 W BROADWAY STE 2
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-4848
Mailing Address - Country:US
Mailing Address - Phone:262-544-0687
Mailing Address - Fax:262-544-0715
Practice Address - Street 1:250 W BROADWAY STE 2
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-4848
Practice Address - Country:US
Practice Address - Phone:262-544-0687
Practice Address - Fax:262-544-0715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health
No347C00000XTransportation ServicesPrivate Vehicle