Healthcare Provider Details

I. General information

NPI: 1710560610
Provider Name (Legal Business Name): BROADSTEP-WISCONSIN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2021
Last Update Date: 04/29/2021
Certification Date: 04/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 LAWRENCE ST
FREDONIA WI
53021-9433
US

IV. Provider business mailing address

5555 N 51ST ST
MILWAUKEE WI
53218-3308
US

V. Phone/Fax

Practice location:
  • Phone: 262-692-2817
  • Fax:
Mailing address:
  • Phone: 414-527-6970
  • Fax: 414-527-6971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: JULIANNE YOPPS
Title or Position: EXECUTIVE ASSISTANT
Credential:
Phone: 414-930-4421