MEDICARE: EASTCASTLE PLACE, INC.

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	310400000X	Assisted Living Facility	0069	WI
2	314000000X	Skilled Nursing Facility	1032	WI

General Provider Information

NPI Number	:	1518941798
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTCASTLE PLACE, INC.

Provider Business Mailing Address
First Line	:	2505 E BRADFORD AVE.
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53211
Country	:	US
Telephone Number	:	414-963-8481
Fax Number	:	414-332-3440

Provider Business Practice Location Address
First Line	:	2429 E BRADFORD AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53211-4100
Country	:	US
Telephone Number	:	414-963-6151
Fax Number	:	414-332-3440

Authorized Official
Title or Position	:	CHAIRMAN
Name	:	NANCY A O'DONNELL
Credential	:
Telephone Number	:	414-588-4828

Provider Enumeration Date	:	12/01/2005
Last Update Date	:	07/16/2019

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