MEDICARE: METHU ADULT FAMILY CARE HOME II

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	0015250	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0015250	OTHER	WI	STATE OF WISCONSIN

General Provider Information

NPI Number	:	1942605670
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	METHU ADULT FAMILY CARE HOME II

Provider Business Mailing Address
First Line	:	3070 N 55TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53210-1563
Country	:	US
Telephone Number	:	414-466-8930
Fax Number	:	414-873-4501

Provider Business Practice Location Address
First Line	:	2824 N 59TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53210-1504
Country	:	US
Telephone Number	:	414-466-8930
Fax Number	:	414-873-4501

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JAMES MWANGI METHU
Credential	:
Telephone Number	:	414-466-8930

Provider Enumeration Date	:	10/23/2014
Last Update Date	:	10/23/2014

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