Healthcare Provider Details

I. General information

NPI: 1194688747
Provider Name (Legal Business Name): IDEAL COMMUNITY LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 W BROWN DEER RD STE C9
BROWN DEER WI
53209-1220
US

IV. Provider business mailing address

PO BOX 1111
WEST BEND WI
53095-8611
US

V. Phone/Fax

Practice location:
  • Phone: 262-469-1053
  • Fax: 855-853-8249
Mailing address:
  • Phone: 414-698-0990
  • Fax: 855-853-8249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QB0505X
TaxonomyDiabetology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code132700000X
TaxonomyDietary Manager
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207QD0401X
TaxonomyDiabetology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 14
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number
License Number State
# 15
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: DANA CATRICE PERRY
Title or Position: OWNER
Credential:
Phone: 262-469-1053