Healthcare Provider Details

I. General information

NPI: 1023899713
Provider Name (Legal Business Name): MISSION RESPITE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2023
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2980 CAHILL MAIN STE 205A
FITCHBURG WI
53711-7146
US

IV. Provider business mailing address

2980 CAHILL MAIN STE 205A
FITCHBURG WI
53711-7146
US

V. Phone/Fax

Practice location:
  • Phone: 608-770-8929
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: JEREMY TYLER
Title or Position: CEO
Credential:
Phone: 608-770-8929