Healthcare Provider Details

I. General information

NPI: 1679281109
Provider Name (Legal Business Name): FAMILY 1ST PNCC SERVICES, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4435 N 49TH ST
MILWAUKEE WI
53218-5702
US

IV. Provider business mailing address

4435 N 49TH ST
MILWAUKEE WI
53218-5702
US

V. Phone/Fax

Practice location:
  • Phone: 414-520-6574
  • Fax:
Mailing address:
  • Phone: 414-520-6574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name: MATANYA L. BOYD
Title or Position: HEALTH EDUCATOR/CO-OWNER
Credential:
Phone: 414-520-6574