Healthcare Provider Details

I. General information

NPI: 1154750511
Provider Name (Legal Business Name): MED GROUP ADULT DAY CARE OF WI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2013
Last Update Date: 11/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6572 S LOVERS LANE RD
FRANKLIN WI
53132-1209
US

IV. Provider business mailing address

11402 N PORT WASHINGTON RD SUITE 215
MEQUON WI
53092-3447
US

V. Phone/Fax

Practice location:
  • Phone: 414-755-0558
  • Fax: 414-755-2470
Mailing address:
  • Phone: 414-755-0558
  • Fax: 414-755-1763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number0014565
License Number StateWI

VIII. Authorized Official

Name: DARIKO MEKVABISHVILI
Title or Position: PRESIDENT
Credential:
Phone: 414-755-0558