Healthcare Provider Details

I. General information

NPI: 1992676902
Provider Name (Legal Business Name): FULLY LOADED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2025
Last Update Date: 09/15/2025
Certification Date: 09/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 W FAIRMOUNT AVE
MILWAUKEE WI
53209-5721
US

IV. Provider business mailing address

1810 W FAIRMOUNT AVE
MILWAUKEE WI
53209-5721
US

V. Phone/Fax

Practice location:
  • Phone: 262-527-7490
  • Fax:
Mailing address:
  • Phone: 262-527-7490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number StateNULL

VIII. Authorized Official

Name: SHAVONNEY LOCKRIDGE
Title or Position: OWNER
Credential:
Phone: 262-527-7490