MEDICARE: HOMESTEAD TRAIL 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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1376408278
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOMESTEAD TRAIL LLC

Provider Business Mailing Address
First Line	:	1342 W HOMESTEAD TRL
Second Line	:
City	:	MEQUON
State	:	WI
Zip	:	53092-3213
Country	:	US
Telephone Number	:	262-270-6600
Fax Number	:

Provider Business Practice Location Address
First Line	:	1342 W HOMESTEAD TRL
Second Line	:
City	:	MEQUON
State	:	WI
Zip	:	53092-3213
Country	:	US
Telephone Number	:	262-270-6600
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	TYRA ESTAVA
Credential	:	CNA
Telephone Number	:	262-675-3337

Provider Enumeration Date	:	12/22/2025
Last Update Date	:	12/22/2025

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Directions to “HOMESTEAD TRAIL LLC ” Practice Location

Language	Start Address	Practice Location

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