MEDICARE: MS. DIAMOND C CULBEREATH

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	374U00000X	Home Health Aide		WI

General Provider Information

NPI Number	:	1508403064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DIAMOND C CULBEREATH

Provider Business Mailing Address
First Line	:	3444 N TEUTONIA AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53206-2327
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4028 W LANCASTER AVE APT 1
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53209-5266
Country	:	US
Telephone Number	:	414-458-3835
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2019
Last Update Date	:	12/04/2019

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