Healthcare Provider Details

I. General information

NPI: 1962396556
Provider Name (Legal Business Name): GWENMAR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2025
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4230 N 53RD ST
MILWAUKEE WI
53216-1343
US

IV. Provider business mailing address

4230 N 53RD ST
MILWAUKEE WI
53216-1343
US

V. Phone/Fax

Practice location:
  • Phone: 414-699-3518
  • Fax: 520-423-3901
Mailing address:
  • Phone: 414-699-3518
  • Fax: 520-423-3901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number State

VIII. Authorized Official

Name: MRS. GWENLODYN MOSS
Title or Position: OWNER
Credential:
Phone: 414-699-3518