MEDICARE: INDEPENDENT LIFESTYLE SUPPORTIVE HOMECARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker
2	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1306771092
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENT LIFESTYLE SUPPORTIVE HOMECARE LLC

Provider Business Mailing Address
First Line	:	4175 N 62ND ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-1234
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4175 N 62ND ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-1234
Country	:	US
Telephone Number	:	414-308-9770
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LATISHA S LITTLE
Credential	:
Telephone Number	:	414-308-9770

Provider Enumeration Date	:	06/15/2026
Last Update Date	:	06/15/2026

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