MEDICARE: LOVING ELDERLY ADULT DAY CARE CENTER LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	103TM1800X	Intellectual & Developmental Disabilities Psychologist
2	171M00000X	Case Manager/Care Coordinator
3	103TA0700X	Adult Development & Aging Psychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	V5206389587103	OTHER	WI	ID
2	0017963	OTHER	WI	CETIFICATE

General Provider Information

NPI Number	:	1750917589
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOVING ELDERLY ADULT DAY CARE CENTER LLC

Provider Business Mailing Address
First Line	:	7017 N 58TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53223-5204
Country	:	US
Telephone Number	:	414-207-6796
Fax Number	:

Provider Business Practice Location Address
First Line	:	7017 N 58TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53223-5204
Country	:	US
Telephone Number	:	414-207-6796
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NCAIS THAO VANG
Credential	:
Telephone Number	:	414-243-5745

Provider Enumeration Date	:	03/12/2020
Last Update Date	:	03/12/2020

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