Healthcare Provider Details

I. General information

NPI: 1306771092
Provider Name (Legal Business Name): INDEPENDENT LIFESTYLE SUPPORTIVE HOMECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4175 N 62ND ST
MILWAUKEE WI
53216-1234
US

IV. Provider business mailing address

4175 N 62ND ST
MILWAUKEE WI
53216-1234
US

V. Phone/Fax

Practice location:
  • Phone: 414-000-0000
  • Fax: 800-251-9766
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: LATISHA S LITTLE
Title or Position: OWNER
Credential:
Phone: 414-000-0000