Healthcare Provider Details

I. General information

NPI: 1750917589
Provider Name (Legal Business Name): LOVING ELDERLY ADULT DAY CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2020
Last Update Date: 03/12/2020
Certification Date: 03/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7017 N 58TH ST
MILWAUKEE WI
53223-5204
US

IV. Provider business mailing address

7017 N 58TH ST
MILWAUKEE WI
53223-5204
US

V. Phone/Fax

Practice location:
  • Phone: 414-207-6796
  • Fax:
Mailing address:
  • Phone: 414-207-6796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State

VIII. Authorized Official

Name: NCAIS THAO VANG
Title or Position: OWNER
Credential:
Phone: 414-243-5745