Healthcare Provider Details

I. General information

NPI: 1801898127
Provider Name (Legal Business Name): PROMINENT HEALTH CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6263 N GREEN BAY AVE
GLENDALE WI
53209-3823
US

IV. Provider business mailing address

6263 N GREEN BAY AVE
GLENDALE WI
53209-3823
US

V. Phone/Fax

Practice location:
  • Phone: 414-351-0543
  • Fax: 414-351-7977
Mailing address:
  • Phone: 414-351-0543
  • Fax: 414-351-7977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number3218
License Number StateWI

VIII. Authorized Official

Name: MS. SUZANNE NAVIN
Title or Position: ADMINSTRATOR
Credential:
Phone: 414-351-0543