Healthcare Provider Details

I. General information

NPI: 1053174391
Provider Name (Legal Business Name): MIRACLE HOPE SUPPORTIVE HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2024
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4467 N 85TH ST
MILWAUKEE WI
53225-5141
US

IV. Provider business mailing address

5202 W LISBON AVE
MILWAUKEE WI
53210-2749
US

V. Phone/Fax

Practice location:
  • Phone: 920-815-5158
  • Fax:
Mailing address:
  • Phone: 414-275-7044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. CENCREAHA E BOWMAN
Title or Position: CEO
Credential:
Phone: 920-815-5158