Healthcare Provider Details

I. General information

NPI: 1669221347
Provider Name (Legal Business Name): SOUTHPORT HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2024
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 52ND ST STE 300
KENOSHA WI
53140-3423
US

IV. Provider business mailing address

600 52ND ST STE 300
KENOSHA WI
53140-3423
US

V. Phone/Fax

Practice location:
  • Phone: 262-656-8400
  • Fax:
Mailing address:
  • Phone: 262-656-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State

VIII. Authorized Official

Name: AMBER L TUELLER
Title or Position: CORPORATE SECRETARY
Credential:
Phone: 208-401-1400