Healthcare Provider Details

I. General information

NPI: 1528437498
Provider Name (Legal Business Name): ETERNITY HOMECARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2015
Last Update Date: 09/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 GREENWAY CROSS SUITE 101
MADISON WI
53713-3181
US

IV. Provider business mailing address

1402 GREENWAY CROSS SUITE 101
MADISON WI
53713-3181
US

V. Phone/Fax

Practice location:
  • Phone: 608-251-2273
  • Fax: 866-748-3232
Mailing address:
  • Phone: 608-251-2273
  • Fax: 866-748-3232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number100014484
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number100014484
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number100014484
License Number StateWI
# 10
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: MRS. KELLY KLINE BURNETT
Title or Position: BUSINESS LIAISON
Credential: MBA
Phone: 608-251-2273