Healthcare Provider Details

I. General information

NPI: 1568223931
Provider Name (Legal Business Name): HAVEN OF PEACE SHC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2359 N SHERMAN BLVD
MILWAUKEE WI
53210-2945
US

IV. Provider business mailing address

2359 N SHERMAN BLVD
MILWAUKEE WI
53210-2945
US

V. Phone/Fax

Practice location:
  • Phone: 414-739-7587
  • Fax: 414-434-3222
Mailing address:
  • Phone: 414-739-7587
  • Fax: 414-434-3222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. JALONG M EVANS
Title or Position: OWNER
Credential:
Phone: 414-739-7587